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Digitized  by  the  Internet  Archive 

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http://www.archive.org/details/difficultlabourgOOhermiala 


DIFFICULT     LABOUR 


WORKS  BY 

G.    ERNEST   HERMAN, 

M.B.  Lond.,  F.R.C.P. 


Diseases    of    Women.      A    Clinical    Guide 

to    their    Diagnosis    and    Treatment.      New    and 
Revised  Edition.    With  over  250  Illustrations. 

First    Lines    in    Midwifery.       A    Guide 

to    Attendance    on    Natural     Labour.       With    SI 
Illustrations. 

Cassell  (£  Company,  Limited,  London; 
Paris,  New  York  &  Melbourne. 


Difficult    Labour 

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A    GUIDE   TO   ITS  MANAGEMENT   ' 

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FOE  STUDENTS  AND    PRACTITIONEftfS 


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G.    ERNEST    HERMAN 

M.B.  Lond.,  F.E.C.P. 

CONSULTING  OBSTETRIC  PHYSICIAN  TO  THE  LONDON  HOSPJT\L  ;  CONSULTING 
PHYSICIAN-ACCOUCHEUR  TO  THE  TOWER  HAMLETS  Dlt«>ENSARY  ;  LATE  PRESI- 
DENT OF  THE  OBSTETRICAL  SOCIETY  OF  LONDON  AND  OF  THE  HUNTERIAN 
SOCIETY;  FORMERLY  PHYSICIAN  TO  THE  GENERAL  LVlNG-IN  HOSPITAL, 
AND  TO  THE  EASTERN  DISTRICT  OF  THE  ROYAL  MATERNITY  CHARITY,  AND 
EXAMINER  IN  MIDWIFERY  TO  THE  UNIVERSITIES  OF  LONDON,  OXFORD, 
CAMBRIDGE,  AND  DURHAM,  THE  VICTORIA  UNIVERSITY,  THE  ROYAL  COLLEGE 
OF   SURGEONS,    AND   ROYAL   COLLEGE   OF  PHYSICIANS 


WITH    165    ILLUSTRATIONS 


NEW     EDITION 


NEW    YORK 

WILLIAM     WOOD     and     COMPANY 

MDCCCCVIII 


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GEORGE     ROPER,     M.D. 

MY    PREDECESSOR    IN    THE    SERVICE    OF    THE 

ROYAL    MATERNITY    CHARITY, 

IX    GRATITUDE    FOR   MUCH    PERSONAL    KINDNESS, 

MUCH    PRACTICAL    INSTRUCTION, 

AND    IN    ADMIRATION 

FOR    AN    HONOURABLE    PROFESSIONAL    CAREER. 


PREFACE. 

Experience  as  a  practitioner  and  teacher  of  Mid- 
wifery, and  as  an  examiner  in  that  subject,  has  led 
me  to  think  that  a  book  was  wanted  which  should 
give  the  reader  more  definite  guidance  in  practice 
than  he  gets  from  some,  in  other  respects  excellent 
text-books  of  the  present  day.  The  learner  finds  in 
them  many  different  things  that  he  may  do :  but  he 
is  not  always  clearly  told  which  is  the  best.  I  have 
tried  to  tell  him  as  clearly  as  I  can  what  I  think  the 
best  way  of  dealing  with  each  complication  of  labour, 
and  why  I  think  so.  An  experience  in  difficult 
labour  larger  than  that  of  most  persons,  is  my  excuse 
for  thinking  myself  competent  to  do  this.  I  have  not 
aimed  at  giving  a  full  representation  of  all  current 
opinions,  nor  at  directing  the  reader  to  the  original 
sources  of  information  upon  the  facts  described, 
although  I  have  put  a  few  references  to  papers  of 
interest. 

If   the  style   of   the   book    should   seem  unduly 

dogmatic,   I  would   plead   in   extenuation  the  words 
* 


x  Difficult  Labour. 

of  Bacon  :  "  The  manner  of  the  tradition  and  delivery 
of  knowledge,  which  is  for  the  most  part  magistral 
and  peremptory  ....  in  a  sort  as  may  be  soonest 
believed  and  not  easiliest  examined  ....  in  com- 
pendious treatises  for  practice  ....  is  not  to  be 
disallowed." 

I  have  acknowledged  in  the  text  the  sources 
whence  illustrations  have  been  borrowed,  so  far  as  I 
have  been  able  to  ascertain  them.  If  this  has  been 
omitted  in  any  case,  it  is  from  inadvertence,  not  from 
design. 

I  have  to  thank  Dr.  Cullingworth  for  the  great 
service  of  reading  the  proof-sheets,  and  correcting 
many  faults. 


PREFACE    TO    1NEW   EDITION. 

In  preparing  this  New  Edition  for  the  press,  I  have 
gone  carefully  through  the  book,-  and  amended  and, 
I  hope,  improved  it,  chiefly  in  matters  of  minor 
detail.  I  have  added  a  chapter  on  the  Rapid  Methods 
of  Delivery  recently  introduced.  I  have  to  thank 
Dr.  Russell  Andrews  for  some  valuable  suggestions. 

April,  1906. 


CONTENTS. 


FAQS 

CHAPTER  L. 
What  is  Natural  Labour  ? ; ,        ,        ,       1 

CHAPTER  II. 
Difficult  Occipito-posterior  Positions 8 

CHAPTER  III. 
Face  and  Brow  Presentations  ........      15 

CHAPTER  IV. 
The  Moulding  of  the  Head       ........      29 

CHAPTER  V. 
Pelvic  Presentations  .        .........      34 

CHAPTER  VI. 
Transverse  Presentations 62 

CHAPTER  VIL 
Prolapse  of  Extremities    .       .       :        .       .       .       .       .       .77 

CHAPTER  VIII. 
Anomalies  of  the  Umbilical  Cord    .......      81 

CHAPTER  IX. 
Twins .......04 

CHAPTER  X. 
Malformed  Children ,       .        .       .        .    108 

CHAPTER  XI. 
Abnormal  Uterine  Action  .........    114 

CHAPTER  XII. 
The  Common  Forms  of  Contracted  Pelvis 138 

CHAPTER  XIII. 
The  Results  of  Contracted  Pelvis 148 

CHAPTER  XIV. 
The  Diagnosis  of  Pelvic  Contraction 184 


xiv  Difficult  Labour. 

CHAPTER  XV.  page 

The  Mechanism  or  Labour  with  Contracted  Pelvis    .       .        .    180 

CHAPTER  XVI, 
Treatment  of  Labour  with  Contracted  Pelvis     ....    193 

CHAPTER  XVIL 
Thx  Rare  Forms  of  Contracted  Pelvis 211 

CHAPTER  XVIII. 
Slow  Dilatation  of  the  Soft  Parts  .     ,  .       .       .        .       .246 

CHAPTER  XIX. 
Labour  complicated  with  Tumours 254 

CHAPTER  XX. 
BupTURS  of  the  Uterus 263 

CHAPTER  XXI. 
The  Injuries  to  the  Genital  Canal  in  Childbirth      .  .    281 

CHAPTER  XXII. 
Hemorrhage  before  Delivery 292 

CHAPTER  XXIII. 
Hemorrhage  before  Delivery  (concluded)       .....    802 

CHAPTER  XXIV. 
Hemorrhage  after  Delivery    f 326 

CHAPTER  XXV. 
The  Forceps 353 

CHAPTER  XXVL 
Turning 880 

CHAPTER  XXVII. 
Operations  for  Lessening  the  Child's  Size  ......    392 

CHAPTER  XXVIIL 
Cesarian  Section 409 

CHAPTER  XXIX. 
Symphysiotomy .       .  424 

CHAPTER  XXX 
The  Induction  of  Premature  Labour      ......    429 

CHAPTER    XXXI. 

Methods  of  Rapid  Delivery 439 

Index 442 


LIST    OF    ILLUSTEATIONS. 


MM 

Bregmato-cotyloid  Position :  head  flexed 8 

Showing  the  Rotation  that  should  take  place  in  Occipi to- posterior 

Positions 4 

Fronto-cotyloid  Position :  the  occipitofrontal  diameter  lying  across 

the  pelvis 5 

Taken  from  a  Photograph  of  a  frozen  Section  by  Pinard  and  Varnier, 

showing  Extension  of  the  Spine  when  the  Occiput  lies  behind  .  6 
Head  presenting  at  Brim;   Occiput  in  front;  bi-parietal  Diameter 

lying  in  oblique  Diameter  of  Pelvis 7 

Head  presenting  at  Brim ;   Occiput  behind ;  bi-parietal  Diameter 

lying  behind  oblique  Diameter  of  Pelvis 7 

Showing  Mode  of  Delivery  when  Occiput  does  not  rotate  forwards     .        8 

Showing  Forceps  Delivery  with  Occiput  behind 11 

The  Vectis 13 

Showing  how,  when  Extension  of  the  Head  has  begun,  Uterine  Con- 
traction increases  it 18 

Attitude  in  Face  Presentation,  showing  complete  Extension  of  Head  .  17 
Showing  the  Effect  of  Uterine  Obliquity  in  causing  Face  Presentation  18 
Showing  Mode  of  rectifying  Face  Presentation  by  pressing  the  Face  up 

and  the  Occiput  down 23 

Showing  Schatz's  Method  of  rectifying  Face  Presentation  ...  23 
Face  sunk  down  into  Pelvis  with  Chin  behind  :  wedge-like  blocking 

of  brim  of  pelvis  by  cranium  and  chest 25 

Showing  Rotation  of  Chin  forwards  which  should  take  place  when 

the  Chin  is  behind 28 

Diagram  showing  the  Direction  of  greatest  Squeeze  in  Delivery  with 

Vertex  in  advance  and  Occiput  in  front :  head  compressed  in 

sub-occipito-frontal  diameter SO 

Diagram  showing  the  Direction  of  greatest  Squeeze  in  Delivery  with 

Vertex  in  advance  and  Occiput  behind :  head  compressed  in 

occipitofrontal  diameter .80 


XV1  Difficult  Labour. 

paoi 
Diagram  showing  the  Direction  of  greatest  Squeeze  in  Delivery  with 
the    Face   presenting :    head  compressed    in   cervico-vertical 

diameter 31 

Drawing  of  an  actual  Skull  after  Delivery  with  the  Face  in  advance  .  SI 
Diagram  showing  Direction  of  greatest  Squeeze  in  Delivery  in  Position 
of  Brow  Presentation:    head  compressed  in    vertico-mental 

diameter 32 

Drawing  of  an  actual  Skull  after  Delivery  in   Position  of  Brow 

Presentation 33 

Diagram  showing  how  Obliquity  of  the  Uterus  produces  Footling 

Presentation 85 

Bringing  down  one  Foot 39 

Bringing  down  a  Leg       ..        .' 40 

Digital  Traction  on  Posterior  Hip 43 

Blunt  Hook 45 

Bringing  down  the  Arms 47 

Dorsal  Displacement  of  Arm 49 

Delivery  of  Head  by  combined  Jaw  and  Shoulder  Traction ...  53 
The  so-called  "Prague"  Method   of  Delivering   the   after-coming 

Head       .        .                55 

Delivery  of  after-coming  Head  with  Face  anterior  :  head  flexed  .        .  57 
Delivery  of  after-coming  Head  with  Face  anterior  :  head  extended     .  58 
Showing  the  earliest  Stage  in  the  Production  of  transverse  Presenta- 
tions by  Uterine  Obliquity  :  that  which  is  probably  often  spon- 
taneously rectified 64 

Showing  what  takes  place  in  spontaneous  Version :  descent  of  breech, 

ascent  of  shoulder 67 

Spontaneous  Evolution  in  Progress  :  arm  outside  vulva,  side  of  neck 

behind  pubes,  side  of  chest  pressing  on  perineum      ...  69 
Further  Stage  of  spontaneous  Evolution:   side  of  neck  still  fixed 

behind  pubes,  chest  and  pelvis  delivered,  legs  about  to  follow  .  70 
Termination  of  spontaneous  Expulsion  :  delivery  of  trunk  and  lower 

extremities  complete,  head  and  posterior  arm  about  to  follow  .  71 
Spontaneous  Expulsion :  child  doubled  up,  legs  and  head  expelled 

together 72 

Prolapse  of  Feet  with  Arms  and  Cord 80 

Atrophy  of  Whartonian  Jelly  from  Torsion  of  Cord      ....  81 

Prolapse  of  Cord  by  the  Side  of  the  Head 84 

Postural  Treatment  of  Prolapse  of  Funis 88 

Cord  snared  by  Catheter  with  Stilette 91 

Replacement  of  Cord  by  Catheter 92 

Twin  pregnancy  :  both  presenting  with  the  head 95 


List  of  Illustrations.  xvii 

PADS 

Showing  interlocking  of  Twins  :  first  child  partly  delivered  with 

pelvic  end  in  advance,  second  with  head  .  #  .  .  .  .99 
Showing  interlocking  of  Twins  :  head  of  first  child  descending  into 

pelvis,  second  child  lying  transversely  ....  100 
Locking  of  Twins  :  one  foetus  partly  delivered  with  breech  in  advance, 

the  other  lying  transversely 101 

Hydrocephalus  of  the  Foetus 106 

Foetus  with  Distension  of  Urinary  Bladder  from  imperforate  Urethra .  109 

Double-headed  Monster 112 

Pelvis  of  Foetus  at  Term 135 

Pelvis  of  Adult .  136 

Sagittal  Section  of  Normal  Pelvis 139 

Sagittal  Section  of  Flat  Pelvis        .     • 140 

8agittal  Section  of  Small  Round  Pelvis 141 

Diagram  of  the  Brim  of  the  Small  Round  Pelvis 142 

Diagram  of  the  Cavity  of  the  Small  Round  Pelvis        ....  143 

Sagittal  Section  of  Flat  Rickety  Pelvis 143 

Diagram  of  Rickety  Flat  Pelvis 144 

Rickety  Flat  Pelvis 145 

Diagram  of  Brim  of  Small  Flat  Rickety  Pelvis 145 

Diagram  of  Pelvic  Cavity  in  Small  Flat  Rickety  Pelvis        .       .        .  146 

Showing  what  is  meant  by  "  Pendulous  Belly  " 150 

Showing  Pressure  Marks  on  Head  after  a  Labour  with  Flat  Pelvis  .  156 
8howing  Pressure  Marks  on  Head  after  a  Labour  with  Small  Round 

Pelvis 156 

Showing  Mark  made  by  Promontory  in  Delivery  of  the  after-coming 

Head 164 

Showing  Change  in  Shape  of  Head  produced  by  Traction  with  Base  in 

advance 168 

Duncan's  Callipers 167 

Mode  of  Measuring  the  Diagonal  Conjugate 175 

Direct  Pelvimetry  :  measurement,  four  inches 177 

Direct  Pelvimetry  :  measurement,  three  inches  and  a  half  .       .  177 

Direct  Pelvimetry  :  measurement,  three  inches  and  a  quarter     .        .  177 

Direct  Pelvimetry :  measurement,  three  inches 177 

Direct  Pelvimetry  :  measurement,  two  inches  and  a  half     .       .        .  178 

Position  in  which  the  Head  enters  the  Brim  of  the  Flat  Pelvis    .        .  182 

Obliquity  of  Naegele :  the  sagittal  suture  near  the  sacral  promontory  183 
Posterior  parietal  Obliquity :   sagittal  suture  nearer  the  symphysis 

pubis  than  the  promontory 185 

Posterior  parietal  Obliquity  in  easy  Labour  with  small  Child      .        .  180 

Showing  Thinning  of  lower  Uterine  Segment         .       .       .       . .      .  201 


xviii  Difficult  Labour. 

PAGE 

Showing  what  is  meant  by  "Penduloua  Belly" 208 

Showing  Change  in  Shape  of  Head  produced  by  Traction  with  Base  in 

advance 208 

Showing  Change  in  Shape  of  Head  produced  by  downward  pressure 

with  Vertex  in  advance 206 

Diagram  of  the  generally-contracted  flat  non-rickety  Pelvis         .        .  211 

Diagram  of  pelvic  Cavity  of  generally-contracted  flat  non-rickety  Pelvis  212 

Dwarfs  Pelvis 213 

Diagram  of  Cavity  of  funnel-shaped  Pelvis  in  Sagittal  Plane        .        .214 

Diagram  of  Cavity  of  funnel-shaped  Pelvis  in  Coronal  Plane       .        .  215 

Pseudo-osteomalacic  rickety  Pelvis 216 

Skolio-rachitic  Pelvis 217 

Diagram  of  Brim  of  Skolio-rachitic  Pelvis 219 

Diagram  of  Cavity  of  Skolio-rachitic  Pelvis 219 

Diagram  illustrating  the  Production  of  Kyphotic  Pelvis       .        .        .221 

Kyphotic  Pelvis 222 

Diagram  of  Cavity  of  Kyphotic  Pelvis  in  Sagittal  Plane       -       .        .  223- 

Diagram  of  Brim  of  Kyphotic  Pelvis 224 

Kypho-skolio-rachitic  Pelvis 226 

Diagram  of  Brim  of  Kypho-skolio-rachitic  Pelvis 227 

Diagram  of  Cavity  of  Kypho-skolio-rachitic  Pelvis       .       .       .       .227 

Osteomalacic  Pelvis 228 

Obliquely-contracted  Pelvis  of  Naegele 232 

Diagram  of  the  Brim  of  the  Oblique  Pelvis  of  Naegele .        .        .        .233 

Transversely- contracted  Pelvis  of  Robert 235 

Lumbar  Vertebra:  showing  the  defect  in  ossiflcation  upon  which 

spondylolisthesis  depends 236 

Spondylolisthesis    .                        237 

Spondylizema  ...               240 

Split  Pelvis 242 

Pelvis  of  Congenital  Dislocation  of  the  Hips 243 

Ovarian  Tumour  Obstructing  Delivery  .......  255 

Labour  impeded  by  Uterine  Polypus 257 

Sacral  Exostis 260 

Cancerous  Growths  from  Pelvic  Bones 261 

Diagram  showing   Thickening  of  the  upper  Part  of  the  Uterus 
Thinning  and  Stretching  of  the  lower  Uterine  Segment ;  Labour 

obstructed  by  Hydrocephalus 267 

Showing  Thinning  of  lower  Uterine  Segment 268 

Ruptured  Uterus,  showing.  Retraction  Ring  at  Level  of  firm  Attachment 
of  Peritoneum  ;  Thinning  of  Cervix  ;  gradual  Thinning  of  lower 

Uterine  Segment  from  Retraction  Ring  down  to  Os  Internum   .  269 


List  of  Illustrations.  xix 

PAOB 

8howing  extemporised  raised  Pelvis  Position 278 

Central  Rupture  of  the  Perineum 284 

Central  Rupture  of  the  Perineum 2S5 

Half-curved  Needle 2S8 

Needle- holder 288 

Accidental  Haemorrhage 294 

Diagram  to  show  the  "  Dangerous  "  or  "  Cervical  "  Zone    .        .        .  302 

Placenta  "  Praevia  " 303 

Hour-glass  Contraction  of  the  Uterus 329 

How  to  compress  the  Uterus  to  stop  post-partum  Haemorrhage  .        .  341 

Commencing  Inversion  of  Uterus 346 

Intravenous  Saline  Injection 351 

Dauber's  Forceps 361 

Showing  first  Stage  of  Introduction  of  lower  Blade  of  Forceps  :  blade 

passed  in  antero-posterior  direction,  its  tip  impinging  on  left 

sacro-sciatic  ligament 369 

8howing  second  Stage  of  Introduction  of  lower  Blade  of  Forceps : 

point  moving  upwards  and  forwards  around  head  into  left  side 

of  pelvis 370 

Showing  successive  Positions,  1,  2,  3,  of  lower  Blade  of  Forceps 

during  its  Introduction 371 

Showing  last  Stage  of  Introduction  of  lower  Blade  of  Forceps  and 

first  Stage  of  Introduction  of  upper  Blade :  handle  of  first 

blade  well  back :    second  j  blade  entered  in   antero-posterior 

direction,  tip  impinging  on  right  sacro-sciatic  ligament  .  .  372 
Showing  successive  Positions,  1,  2,  of  upper  Blade  of  Forceps  during 

its  Introduction 373 

Showing  Forceps  locked  and  grasped  by  the  Hands  ;  line  of  traction 

as  nearly  as  possible  in  axis  of  brim 374 

Showing  last  Stage  of  Extraction  ;  the  dotted  line  a  b  shows  the 

"pendulum  movement" 375 

Showing  how  it  is  possible  to]  pull  in  the  Axis  of  the  Pelvic  Brim 

with  the  ordinary  Forceps 376 

Axis  traction  Forceps  :  pattern  of  Cullingworth 378 

Showing  Commencement  of  Bipolar  Version  with  Head  presenting  .  384 
Showing  Commencement  of  Bipolar  Version  with  Shoulder  presenting 

(second  stage  of  version  when  head  presents)  ....  385 
Showing  Continuation  of  Bipolar  Version  :  seizure  of  knee  .        .        .386 

Showing  final  Stage  of  Bipolar  Version  ;  bringing  down  a  leg               .  387 

Showing  Internal  Version 388 

Showing  Fixation  of  Shoulder  below  Os  Internum        ....  398 

Oldham's  Perforator                393 


xx  Difficult  Labour. 

PAOB 

Crotchet 894 

Roper's  Craniotomy  Forceps,  with  English  Lock 896 

Craniotomy  Forceps,  with  Pivot  and  Slot,  and  Screw  attached  .        .  397 

Oldham's  Vertebral  Hook 398 

Showing  the  Base  of  the  Skull  seized  by  the  Craniotomy  Forceps 

Face  first  after  Removal  of  the  Cranial  Vault      .        .        .        .399 

Showing  the  Base  of  the  Skull  being  drawn  through  the  Brim  Face  first  400 

Hicks's  Cephalotribe 401 

Showing  the  Cephalotribe  applied 402 

Showing  Wedge-like  Impaction  of  Shoulder  Presentation     .        .        .  404 

Decapitation 406 

Decapitation  :  extraction  of  trunk 407 

Showing  Position  of  Sutures  in  relation  to  Structures  in  Uterine  Wall  414 
Showing  the  Sutures  when  tied :  peritoneal  surfaces  being  brought 

into  contact  by  the  superficial  sutures        .        .        .        .  ■      .  415 

Showing  the  "  Button-hole "  Stitch 416 

Showing  Wound  closed  with  deep  Stitches  and  superficial  "  Button- 
hole "Stitch  417 

Mode  of  Stitching  Cervical  Stump 421 

Diagram  showing  Change  in  Size  of  Pelvis  effected  by  Symphysiotomy  425 

Tenotomy  Knife 426 

Strapping  to  draw  together  Parts  after  Symphysiotomy       .        .        .  427 

Champetier's  Bag,  folded,  in  Grasp  of  Forceps  for  Introduction  .        .  436 

Champetier's  Bag,  distended  ;. 436 


difficult  labour 

CHAPTER  I. 

WHAT    IS   NATURAL    LABOUR  1 

What  is  natural  labour  ? — Various  definitions 
have  been  given  by  different  authors,  which  it  is  not 
necessary  to  quote  and  discuss.  Labour  is  natural 
when  the  mother  is  in  good  health,  and  the  pelvis  is  of 
not  less  than  normal  size ;  when  the  child  is  living 
and  of  not  more  than  normal  size ;  when  the  vertex 
presents,  .and  the  child's  back  is  in  front ;  when  the 
membranes  do  not  rupture  until  the  os  is  at  least 
three-quarters  of  its  full  size ;  when  the  placenta  is 
implanted  above  the  lower  segment  of  the  uterus,  and 
is  not  detached  until  the  child  is  born  ;  when  uterine 
contraction  and  retraction  go  on  at  such  a  rate  that 
the  child  is  born  within  twenty-four  hours  from  the 
beginning  of  the  labour  pains,  and  continue  after  the 
child  is  born. 

Importance  of  early  diagnosis.— If  these  con- 
ditions are  fulfilled,  almost  the  only  danger  is  that  of 
septic  infection  ;  and  the  patient  would  do  quite  as 
well  without  a  doctor  as  with  one.  But  we  can  never 
foretell  that  all  these  conditions  will  be  fulfilled,  and, 
therefore,  a  woman  who  has  not  a  skilled  attendant 
with  her  in  labour  runs  some  risk.  The  mother  can 
be  safely  delivered  in  spite  of  almost  every  complica- 
tion that  makes  labour  difficult  if  the  abnormal  con- 
ditions are  recognised  early,  and  the  proper  treatment 
applied  in  time.  And  with  almost  every  complication 
labour  is  sometimes,  if  the  other  ch'cumstances  of  the 
case  are  favourable,  successfully  terminated  by  the 
natural  efforts. 

B— 36 


2  Difficult  Labour. 

Examples. — Thus,  in  the  slighter  forms  of  con- 
traction of  the  pelvis,  the  danger  to  the  mother,  if  the 
existence  and  degree  of  pelvic  contraction  are  known 
at  the  beginning  of  pregnancy,  or  even  at  the  beginning 
of  labour,  is  no  greater  than  if  the  pelvis  were  normal; 
but  it  is  very  much  greater  if  the  smallness  of  the  pelvis 
is  only  discovered  by  the  failure  of  prolonged  attempts 
to  drag  the  child  through  it.  If  the  deformity  be  so 
great  that  Csesaiian  section  is  required,  the  danger  of 
this  operation  is  not  one-tenth  as  great,  when  done  at 
a  time  appointed  before  labour  has  begun,  so  that 
preparation  can  be  made  and  skilful  assistance  had,  as 
it  is  when  postponed  until  the  patient  has  been  ex- 
hausted by  fruitless  labour.  Abnormal  presentations 
can.  be  easily  set  right  at  the  proper  time,  but  are 
very  difficult  of  correction  when  that  time  has  passed. 
The  average  death  rate  of  placenta  prawia,  when  pro- 
perly treated,  is  only  about  five  per  cent.  ;  but  it  is 
much  higher  when  wrongly  treated ;  and  it  cannot  be 
properly  treated  unless  the  patient  is  seen  early. 


CHAPTER    II. 

DIFFICULT   OCCIPITO-POSTERIOR    POSITIONS. 

The  kind  of  difficulty  that  I  shall  first  consider  is  that 
due  to  unusual  positions  of  the  child.  I  shall  assume 
in  the  chapters  relating  to  this  kind  of  ditficulty  that 
everything  but  the  position  of  the  child  is  normal. 

The  exceptional  position  which  deviates  the  least 
from  the  normal,  is  that  in  which  the  vertex  presents, 


Fig.  1.— Bregmato-cotyloid  Position  :  head  flexed. 

but  the  child's  belly  is  turned  forwards  instead  of 
backwards  ;  in  other  words,  occipito-posterior  positions. 

Easy  and  difficult  occipito-posterior  labour. 

— Cases  in  which  the  vertex  presents  with  the  occiput 
behind,  are  divided  into  two  groups.  In  one,  the 
larger,  the  head  is  well  flexed,  so  that  the  anterior  fon- 
tanelle,or  bregma,  lies  opposite  the  acetabulum  (Fig.  1). 
These  cases  are  called  bregmato-cotyloid,  and  are  the 
favourable  ones.  In  them  the  occiput  comes  down, 
it  meets  the  resistance  of  the  pelvic  floor,  and  by  this 
resistance  is  pushed  forwards,  so  that  it  turns   from 


4  Difficult  Labour. 

opposite  the  sacro-iliac  synchondrosis  to  under  the 
pubic  arch.  Thus  the  abnormal  position,  with  the 
occiput  behind,  is  changed  into  a  normal  one,  with  the 
occiput  in  front  (Fig.  2).  When  this  rotation  has  taken 
place  the  labour  ends  just  as  if  the  occiput  had  been 
in  front  from  the  beginning  ;  and  no  assistance  is 
required  except  what  may  be  called  for  by  reasons 
other  than  the   position  of  the  child.     Fortunately, 


Fig  2.— Showing  the  Rotation  that  should  take  Place  in  Occi  pi  to-posterior 
Positions. 

the  majority  of  cases  of  vertex  presentation  with  the 
occiput  behind,  end  in  this  way. 

In  the  other  group  of  cases  the  head  is  not  well 
flexed,  and  then,  instead  of  the  anterior  fontanelle 
being  opposite  the  acetabulum,  the  frontal  eminence 
is  opposed  to  it.  These  cases  are  called  fronto-cotyloid 
(Fig.  3). 

Why  flexion  is  imperfect  inoccipito-posterior 

positions. — Extension  of  the  head  in  occipito- posterior 
presentations  comes  about  in  two  ways :  first,  (a)  because 
the  axis  of  the  uterus  and  of  the  pelvic  brim  is  concave 
behind  ;  second,  (b)  because  the  greatest  diameter  of 
the  head  is  behind  its  centra 


Causes  op  Extension.  5 

There  are  other  causes  of  extension  of  the  head,  but 
they  are  not  peculiar  to  the  position  with  the  occiput 
behind.  They  will  be  described  tinder  the  head  of 
face  presentation. 

(a)  The  child  must  accommodate  its  attitude  to  the 
space  in  which  it  lies.  Because  the  axis  of  the  upper 
part  of  the  utero-pelvic  canal  is  concave  behind,  when 
the  back  is  in  front  the  spine  will  be  bent  so  that 
the  child's  abdominal  surface,  which  is  behind,  may 
be  concave.  If  the  child  lies  with  the  abdomen  in 
front,   then  accommodation  to  the    cavity  in  which 


Pig.   3.— Fronto-cotyloid  Position:    the  occipitofrontal   diameter   lying 
across  the  pelvis. 


it  lies  can  only  be  got  by  some  extension  of  the  spine 
(Fig.  4).  If  the  extension  of  the  spine  is  enough  to 
bring  the  occipito-spinal  joint  in  front  of  the  line 
along  which  the  propelling  force  acts,  then  this  force 
will,  unless  opposed,  produce  full  extension  of  the 
head. 

(b)  The  second  reason  why  flexion  is  imperfect 
will  be  understood  if  you  take  the  foetal  skull,  and  hold 
it  in  the  pelvic  brim  in  the  first  position,  when  you 
will  see  that  the  largest  transverse  diameter  of  the 
head,  viz.  the  bi-parietal,  lies  exactly  in  the  oblique 
diameter  of  the  brim,  where  there  is  plenty  of  room 
for  it  (Fig.  5).  Now  turn  it  round,  and  hold  it  with 
the  occiput  behind,  instead  of  in  front.      You  will  see 


6  Difficult  Labour. 

that  the  bi-parietal,  instead  of  being  in  the  oblique 
diameter  of  the  brim,  is  behind  it,  in  a  pai*t  of  the 
pelvis  where  there  is  less  room  for  it  (Fig.  6).  Hence, 
when  the  occiput  is  behind,  it  does  not  come  down 
so  easily  as  when  it  is  in  front,   and  its  descent  is 


Fig.  4, — Taken  from  a  Photograph  of  a  frozen  Section  by  pinard  and 
Varnier,  showing  Extension  of  the  Spine  when  the  Occiput  lies  behind. 


likely  to  be  hindered  if  the  child  be  very  large,  or 
the  pelvis  rather  smaller  than  usual 

This  mode  of  production  of  extension  does  not  come 
into  play  when  the  child  is  very  small.  On  the  other 
hand,  in  the  case  of  very  small  children,  the  effect  of 
extension  of  the  spine  in  causing  extension  of  the  head 
is  not  opposed  by  the  resistance  of  the  pelvic  bones,  as 
will  be  explained  in  the  next  paragraph. 

Results  of  extension. — If  the  head  is  only  a  little 
extended,  a  fronto-cotyloid  position  is  produced.     If 


Results  of  Extension 


Fig.  5. — Head  presenting  at  Brim  ;  Occiput 
in  front ;  In-parietal  Diameter  lying  in 
oblique  Diameter  of  Pelvis. 


the  extension  goes  farther,  a  brow  presentation.     If 

it  becomes  complete, 

a  face   presentation. 

If     the     head     has 

entered    the    pelvic 

cavity,  the  pressure 

of   the   pelvic   walls 

prevents     extension 

from    going    beyond 

a  slight  degree;  for 

each  increase  in  the 

amount  of  extension 

brings  a   larger  dia- 
meter   of    the    head 

across  the  pelvis.   In 

a     fronto  -  cotyloid 

position   the   occipitofrontal  diameter  (4|  inches)  is 

the   largest  thrown  across   the   pelvis ;   in  the  brow 

position  the  mento-vertical  (5\  inches).    The  fronto- 

cotyloid  can  only  become  changed  into  a  face  position 

by  passing  through  the  brow  position.      But  as  the 

largest  diameter  of   the   pelvic  cavity  is  only  about 

five  inches,  this  is 
impossible  with  a 
child  of  average  size. 
But  above  the  brim 
extension  may  and 
does  go  on  to  the 
production  of  face 
presentation. 

In  the  pelvic 
cavity,  if  the  child 
be  very  small,  an 
occipito    -    posterior 

Fig.  6.— Head  presenting  at  Brim  ;  Occiput    ".  ,    .  % 

behind ;  bi-parietal  Diameter  lying  behind    Changed   into    a    lace 

obkque  Diameter  of  Pelvis.  position,  and  so  de- 

livered.       This    has 
bf.en  observed,*  but,  as  will  be  understood  from  the 
*  "Caseaux,"  edited  by  Tarnier,  tr.  by  Bullock,  p.  325. 


8 


Difficult  Labour. 


reason  given  why  it  should  not  occur,  it  is  very 
rare. 

If  the  occiput  does  not  rotate  forwards,  the  uterus 
drives  it  down,  and  it  revolves  round  the  symphysis 
pubis,  having  the  forehead  as  its  centre  of  rotation 
(Fig.  7),  and  thus  is  born.  Then  the  nape  of  the  neck 
becomes  fixed   against  the   perineum,   and  the  nose, 

mouth,  and  chin  slip 
out  from  behind  the 
symphysis  pubis.  This 
is  the  usual  way,  and 
with  a  full-sized  child 
the  only  way,  of  de- 
livery when  the  occiput 
does  not  rotate  to  the 
front. 

The  head  born  with 
the  occiput  behind 
shows  characteristic  de- 
formity. The  occipito- 
frontal measurement 
is  shortened,  the  verti- 
cal measurements  are 
increased.  The  back 
and  front  of  the  head 
alike  rise  up  steeply 
from  the  face  and  neck 
respectively. 
On  the  average,  labour  with  the  occiput  behind  is 
longer  than  when  the  occiput  is  in  front.  Delivery 
with  the  occiput  behind  is  especially  apt  to  occur  with 
very  small  or  very  large  children.  With  small  children 
extension  can  occur  in  the  pelvis ;  with  large,  it  is 
produced  above  the  brim. 

Cases  in  which  treatment  is  required.— When 

the  occiput  is  behind,  labour  is  likely  to  be  delayed 
because  the  occiput  has  to  make  a  long  rotation  to 
get  forward  under  the  pubic  arch.  Although  this 
rotation  takes  place  in  most  cases,  yet  in  some  (about 
\\   per   cent,  of   vertex   presentations)  it  does  not, 


Fig.  7. —  Showing  Mode  of  Delivery 
when  Occiput  does  not  rotate 
forwards. 


Treatment  in  First  Stage.  g 

because  when  the  head  is  too  extended  the  forehead 
instead  of  the  occiput  is  the  first  part  to  meet  the 
resistance  of  the  pelvic  floor.  Then  we  get  difficulty. 
If  the  child  is  not  unusually  small,  or  the  uterus  un- 
usually strong,  help  will  be  needed.  If  the  forehead 
remains  in  front,  so  that  it  becomes  fixed  behind  the 
pubic  arch,  while  the  occiput  passes  over  the  perineum, 
the  occipitofrontal  diameter  of  the  child  has  to  pass 
the  antero-posterior  diameter  of  the  pelvic  outlet. 
Now  as  this  diameter  measures  on  an  average  four 
inches  and  a  half,  while  the  antero-posterior  diameter 
of  the  outlet  varies  between  four  inches  and  four 
inches  and  a  half,  it  will  be  clear  that  the  head 
cannot  pass  easily. 

The  perineum  is  stretched  more  than  it  should  be, 
for  the  diameter  which  should  distend  the  perineum, 
the  sub-occipito-frontal,  only  measures  four  inches, 
while  here  the  perineum  is  stretched  by  the  four 
inches  and  a  half  of  the  occipito- frontal  diameter. 
Hence  a  bad  rupture  of  the  perineum  is  more  likely 
to  happen  when  the  head  is  delivered  in  this  position. 

1.  Treatment.— Preventive :  Before  rupture 

of  membranes. — The  diagnosis  of  an  occipito  posterior 
position  oughttobe  madeearly,  by  abdominal  palpation. 
Unless  the  patient  be  fat,  or  the  abdominal  walls  rigid, 
it  will  be  easy  for  you,  if  you  have  practised  abdominal 
palpation  as  you  ought  to  practise  it,  to  find  out  that 
the  abdomen  is  in  front  before  the  membranes  have 
ruptured,  and,  if  you  have  been  called  in  time,  before 
the  dilatation  of  the  os  has  begun.  If,  then,  you  are 
called  to  a  case  in  which,  on  palpating  the  abdomen, 
in  place  of  the  broad,  smooth  convexity  of  the  back, 
you  feel  the  little  movable  knobs  which  the  foetal 
limbs  feel  like,  at  once  turn  the  back  forwards. 
Before  the  membranes  have  ruptured,  this  is  easily 
done.  Suppose  that  the  child's  belly  looks  forwards 
and  to  the  left.  Its  anterior  shoulder  will  be  to 
the  right  and  in  front.  Standing  by  the  side  of  the 
patient,  put  your  hands  on  the  abdomen,  the  right  hand 
behind  the  child's  anterior  shoulder,  the  left  hand  in 


io  Difficult  Labour. 

front  of  the  posterior  shoulder.  Then,  by  a  repetition 
of  gentle  pushing  movements,  push  the  anterior  shoulder 
over  towards  the  left  side,  and  the  posterior  shoulder 
towards  the  right  side.  You  will  find  it  quite  easy  to 
move  the  child ;  only,  as  the  pushes  are  given,  not  to 
the  child,  but  to  the  uterus,  part-  of  their  effect  is  to 
move  the  uterus.  Each  push  moves  the  uterus  as  well 
as  the  child,  and  only  slightly  alters  the  position  of 
the  child  in  the  uteras.  But  a  sufficient  repetition  of 
these  movements  will,  unless  the  liquor  ainnii  be 
unusually  deficient,  or  the  child's  mobility  for  some 
other  reason  be  abnormally  restricted,  bring  the  back 
to  the  front.  Then  the  labour  may  be  left  to  take  its 
natural  course.  You  will  sometimes  find  that  this 
simple  change  in  the  position  of  the  child  will  make 
a  head  which  was  above  the  brim  quickly  descend  into 
it,  press  into  the  os  uteri,  and  convert  infrequent  and 
feeble  pains  into  strong  and  rapidly  following  ones. 

2.  Head  engaged  in  the  pelvis.— Supposing 

now  that  the  case  is  not  seen,  or  the  diagnosis  not 
made  until  the  membranes  have  ruptured,  the  os  uteri 
has  become  fully  dilated,  and  the  head  is  engaged  in 
the  pelvis.  Wait  for  two  or  three  hours  after  the  full 
dilatation  of  the  os,  and  longer  if  the  pains  are 
weak  and  infrequent,  to  see  if  the  head  will  rotate 
naturally.  Supposing  it  neither  rotates  nor  advances, 
three  courses  are  open — 

A.  To  pull. 

B.  To  flex. 

C.  To  rotate. 

A.  To  pull. — This  course  has  the  approval  of 
a  high  authority — Robert  Barnes.*  The  abnormal 
position  causes  increased  resistance.  Additional  force 
is  needed.  Apply  forceps ;  pull ;  take  care  not  to 
hinder  rotation,  but  leave  the  turns  to  nature. 

This  is  in  some  cases  good  practice.  If  you  are 
not  called  to  a  case  till  so  late  that  when  you  first 
Bee   it   the   caput  succedaneum  is  so  thick  that  you 

*  "Obstetric  Operation*/'  2nd  edn.,  p.  C2. 


FORCEPS    IN  OCCIPITO-POSTERIOR    POSITIONS.      II 

cannot  feel  the  sutures  and  fontanelles,  and  the  patient 
is  so  fat  or  is  straining  so  that  you  cannot  make  a 
satisfactory  diagnosis  by  abdominal  examination ;  and 
on  the  other  hand  the  head  has  sunk  so  far  into  the 
pelvis  that  it  is  clear  that  there  is  no  obstruction  at 


Fig.  S.— Showing  Forceps  Delivery  with  Occiput  behind.   (.J/i<jr  11.  Barnes.) 


the  brim,  and  your  examination  makes  it  certain  that 
there  is  none  at  the  outlet :  in  these  circumstances  the 
most  comfortable  advice,  and  the  best  practice,  will  be 
to  apply  forceps,  pull,  and  leave  the  turns  to  nature 
(Fig.  8).  But  nature  will  not  always  turn  the  occiput 
forwards.   I  have  known  an  hour's  tugging  with  forceps 


i2  Difficult  Labour. 

fail  to  deliver  because  the  occiput  was  behind,  and 
nature  did  not  effect  the  turn.  If  you  know  the  posi- 
tion of  the  head,  there  is  a  better  practice. 

B.  To  flex. — This  is  a  more  scientific  mode  of  meet- 
ing the  difficulty.  It  imitates  the  natural  mechanism. 
When  the  head  is  well  flexed,  the  occiput  meets  the 
resistance  of  the  pelvic  floor.  The  resisting  parts  are 
behind  and  at  the  sides.  The  occiput,  therefore, 
turns  forward,  where  the  resistance  is  least.  If  the 
head  is  not  flexed  the  occiput  does  not  come  down, 
does  not  meet  this  resistance,  and  does  not  turn  for- 
wards. If  we  can  flex  the  head,  the  occiput  will  come 
down,  and  this  natural  mechanism  will  be  brought  into 
play.  Flexing  means  bringing  down  the  occiput,  and 
from  what  has  been  said,  it  will  be  seen  that  this  is  often 
equivalent  to  overcoming  the  hindrance  to  delivery. 

Methods. — There  are  two  ways  of  doing  this.  The 
effect  of  one  is  only  to  flex.  The  other  pi-oduces 
flexion  and  descent.  First  method,  to  produce  flexion. 
Push  up  the  forehead  with  one  or  two  fingers,  and  in 
doing  so,  direct  the  pressure  in  such  a  way  as  to  press 
the  forehead  not  only  upwards,  but  backwards,  so  as 
to  favour  both  flexion  and  the  turn  of  the  occiput 
to  the  front.  This  is  a  mode  of  treatment  which  is 
harmless.  The  only  objection  to  it  is  that  it  is 
generally  ineffective,  for  what  we  want  is  descent  of 
the  occiput.  We  only  value  flexion  as  an  aid  to  this. 
Second  method,  to  produce  flexion  and  descent.  This 
is  done  with  the  vectis,  an  instrument  like  one  blade 
of  a  pair  of  forceps,  except  that  the  tip  of  the  blade  is 
more  sharply  curved  (Fig.  9).  One  blade  of  a  pair 
of  forceps  may  be  used  if  the  forceps  has  an  excep- 
tionally sharp  curve ;  but  the  forceps  best  suited  to 
the  shape  of  the  head  cannot  be  so  used,  because  the 
blade  is  not  curved  sharply  enough.  The  vectis  is 
introduced  over  the  occiput,  and  with  it  the  occiput 
pulled  down,  and  at  the  same  time  forwards.  This 
is  undoubtedly  an  efficient  way  of  procuring  flexion 
and  descent,  and  helping  rotation  forwards.  Were 
tliis    the   only   or    the    best    way,    it    would    involve 


Rotation  in  Occipito-posterior  Positions.   13 

loading  the  obstetric  bag  with  an  additional  instru- 
ment.    There  is  a  better  and  simpler  way.     This  is  : 

C.  To  rotate. — Put  the  left  hand  in 
the  vagina,  and  the  right  hand  on  the 
abdomen.  Suppose  that  the  occiput  is  be- 
hind and  to  the  right.  The  left  shoulder 
will  be  in  front  and  to  the  right.  Put 
the  right  hand  behind  the  left  shoulder 
of  the  child.  Grasp  the  head  between  the 
thumb  and  four  fingers  of  the  left  hand, 
and,  in  the  interval  between  two  pains, 
turn  the  occiput  forwards ;  at  the  same 
time,  with  the  hand  on  the  abdomen,  press- 
ing the  shoulder  forwards  and  to  the  left. 
If  you  can  succeed  in  rotating  the  head 
and  the  shoulders,  the  head  will  stay  in  its 
new  position.  If  your  rotation  of  the 
shoulders  is  imperfect,  when  you  take  your 
left  hand  away  the  head  will  go  back  into 
its  old  position,  or  nearly  into  it.  If  you 
can  easily  rotate  the  head,  but  there  is 
difficulty  in  getting  the  shoulders  round, 
and  the  passages  are  healthy,  hold  the 
head  in  its  new  position,  and  apply  forceps. 
I  have  repeatedly  by  this  manoeuvre  easily  *1BvectTs!ne 
effected  delivery  with  forceps  in  cases  in  {From  Maw, 
which  prolonged  ineffectual  traction  had  Thompson.) 
been  previously  made. 

Forceps  rotation. — It  has  been  recommended  to 
rotate  with  the  forceps  after  the  instrument  has 
grasped  the  head.  Smellie  quaintly  says  that  it  gave 
him  "  great  joy  "  *  when  he  discovered  this  manoeuvre. 
But  it  is  not  such  good  practice  as  rotating  with  the 
hand :  for  if  you  try  and  twist  the  head  round  with 
the  forceps,  one  edge  of  the  instrument  is  pressed 
strongly  against  the  head,  and  the  other  raised  off  it. 
The  edge  pressed  in  may  injure  the  scalp  or  skull,  and 
the  edge  raised  may  injure  the  mother. 


*  N.  S.  S.  edition,  vol.  u.  p.  339. 


i4  Difficult  Labour. 

It  has  been  objected  to  the  practice  of  rotation  that 
the  ,  child's  neck  may  be  broken  by  it.  It  might, 
perhaps,  if  the  shoulders  were  fixed,  and  the  accou- 
cheur were  resolved  at  all  hazards  to  get  the  occiput 
forwards,  but  it  will  not  be  broken  by  one  careful  not 
to  use  violence.  Very  little  force  is  needed  for 
rotation.  The  shoulders  will,  I  believe,  turn  in  utero 
before  the  neck  will  break.  I  have  never  known  it 
happen,  or  read  of  its  happening,  and  I  think  the 
objection  is .  theoretical,  not  practical.  The  head  will 
6urn  through  three-eighths  of  a  circle  without  dis- 
location, and  this  amount  of  rotation  is  enough  for 
delivery. 


i5 


CHAPTER    III. 

FACE   AND    BROW    PRESENTATIONS. 

Causes. — The  causes  of  face  presentation  looked 
at  broadly  are  as  follows  : — 

1.  The  mechanical  production  of  extension  of  the 
head  by 

(a)  The  size  of  the  pelvis. 
(6)  The  size  of  the  head. 

(c)  The  position  of  the  uterus. 

(d)  The  shape  of  the  head. 

2.  Certain  conditions  which  oppose  normal  pre- 
sentations, but  have  no  special  tendency  to  make 
the  face  present. 

3.  Certain  rare  deformities  of  the  foetus;  abnor- 
malities of  the  cord ;  and  abnormalities  in  the  fcetal 
attitude. 

1.  (a)  The  size  Of  the  pelvis. — Contraction  of  the 
pelvis,  either  flattening,  or  general  contraction  of  the 
pelvis  (and  probably  other  forms  so  much  rarer  that 
we  have  not  enough  observations  about  their  effect  on 
labour  to  enable  anyone  to  speak  from  experience) 
often  leads  to  face  presentations. 

Most  face  presentations  are  caused  by  conditions 
which  prevent  the  occiput  from  getting  easily  into  the 
brim.  If  the  pelvis  is  contracted,  so  that  there  is  not 
room  enough  for  the  bi-parietal  diameter  to  descend 
easily  into  the  pelvis,  and  thus  the  fcetal  head  is 
extended  enough  to  get  the  occipito- vertebral  joint  in 
front  of  the  line  along  which  the  uterine  pressure  acts, 
then  the  uterine  action  will  extend  the  head  more 
and  more  until  a  face  presentation  is  produced  (Fig. 
10).  It  is  not  needful  that  the  uterine  contractions 
should  be  very  strong.  A  small  force  often  applied 
produces  a  great  effect.  Hence  a  face  presentation 
may  be  brought  about  by  the  uterine  contractions  of 


r6  Difficult  Labour. 

pregnancy,  before  labour  has  begun.  These,  although 
not  strong  enough  to  make  the  head  engage  in  the 
brim,  may  yet  be  enough  to  extend  it.  Therefore,  some- 
times the  face  presents  at  the  very  beginning  of  labour, 
before  the  head  has  entered  the  brim  (Fig.  11).    The 


Fig.  10.— Showing  how,  when  Extension  of  the  Head  has  begun,  Uterine 
Contraction  increases  it.    (After  Sehatz.) 

d  the  ioint  between  the  spine  and  the  head,  is  here  in  front  of  the  line  A  b,  along 
which  the  pressure  of  the  uterus  on  the  head  and  breech  is  exerted.  Such 
pressure  tends  to  make  the  angle  u  o  c  more  acute ;  that  is,  to  increase 
extension. 

uterine  contractions  which,  so  to  speak,  try  to  make 
the  face  enter  the  brim,  may  fail  in  this,  but  yet  get 
it  into  the  most  favourable  position  for  entering ;  and 
this,  with  a  flat  pelvis,  is  transverse — chin  towards 
one  side,  forehead  to  the  other.  Therefore,  with  a 
face  presentation  thus  lying,  always  suspect  a  flat 
pelvis.     But  any  kind  of  contracted  pelvis  that  does 


Causes  of  Face  Presentation. 


n 


not  allow  the  bi-parietal  measurement  to  enter  easily, 
may  lead  to  a  face  presentation.  Therefore,  if  the 
face  is  not  lying  transversely,  do  not  conclude  that 
there  is  no  pelvic  contraction. 

(b)  The  size  of  the  head. 

— The  same  thing  may  happen  if 
the  head  is  very  large,  although 
the  pelvis  is  not  contracted. 
Face  presentations  have  been 
proved  to  be  more  common  with 
very  big  children  than  with 
those  of  average  size.  The  effect 
on  labour  of  a  very  big  child, 
the  pelvis  being  normal,  is  the 
same  as  that  of  a  generally  con- 
tracted pelvis  with  a  child  of 
average  size.  Enlargement  of 
the  head  from  hydrocephalus 
will  have  the  same  effect. 

(c)  The  position  of  the 

Uterus. — Uterine  obliquity  is 
a  cause  of  face  presentation,  and 
some  think  it  the  most  common 
cause.  The  obliquity  consists 
in  a  deviation  of  the  body  of  the 
uterus  towards  one  side,  and  it 
most  often  is  to  the  right  side. 
If   the    body  of   the   uterus   is 

deviated  to  the  right,  the  propelling  force  of  the 
uterus,  instead  of  acting  downwards  in  the  middle 
line,  acts  downwards  and  to  the  left.  Hence  it 
tends  to  push  down  more  that  part  of  the  head  which 
is  turned  to  the  left.  If  the  occiput  is  to  the  left,  the 
effect  of  this  action  is  beneficial,  by  increasing  flexion. 
But  if  the  occiput  is  to  the  right,  the  effect  will  be  to 
produce  extension;  and  if  the  head  be  once  so  far 
extended  that  the  occipito-spinal  joint  is  in  front  of 
the  line  along  which  the  uterine  force  acts,  the  effect 
of  uterine  contraction  is  more  and  mox-e  to  increase 
extension  till  a  face  presentation  is  produced  (Fig.  12). 

c— 36 


Fig.  11.— Attitude  in  Face 
Presentation,  showing 
complete  Extension  of 
Head.    (From  Galabin.) 

A  c,  Line  along  which  expul- 
sive force  is  transmitted; 
si  F,  fronto-niental  dia- 
meter of  head. 


1 8  Difficult  Labour. 

The  proof. — This  theoretical  explanation  was 
given  by  the  late  Dr.  Matthews  Duncan.  The  correct- 
ness of  his  reasoning  cannot  be  disputed.  His  view  is 
supported  by  facts.  For  the  common  uterine  obliquity 
is  to  the  right,  and  therefore  it  is  in  positions  in  which 
the  child's  back  is  to  the  right  that,  if  the  theory  be 


Fig.  12.— Showing  the  Effect  of  Uterine  Obliquity  in  causing  Face 
Presentation. 

The  continuous  outline  shows  the  uterus  vertical,  the  child's  head  in  a 
position  midway  between  flexion  and  extension ;  the  line  along 
which  the  uterine  pressure  is  exerted  passing  through  the  occipito- 
spinal  joint.  The  dotted  outline  shows  right  lateral  obliquity  of  uterus, 
the  broken  line  indicating  the  line  along  which  the  uterine  pressure 
now  acts.  The  occipito-spinal  joint  is  now  in  front  of  this  line,  and 
therefore  it  tends  to  extend  the  head  more  a::d  more. 


true,  we  should  expect  face  positions  to  be  produced. 
Now,  in  face  presentations,  positions  with  the  back  to 
the  right  are  nearly  as  common  as  those  with  the  back 
to  the  left,  while  in  vertex  presentations  the  back  is 
three  times  as  often  to  the  left  as  to  the  right. 


Causes  of  Face  Presentation.  19 

Practical   application. — It  follows  from  this 

reasoning  that  the  way  to  prevent  or  undo  face 
presentation  caused  by  uterine  obliquity,  is  to  put  the 
patient  on  the  side  opposite  to  that  towards  which 
the  fundus  uteri  is  deviated,  so  as  to  undo  the  obliquity. 
But  this  can  only  be  effective  if  done  quite  early. 
When  complete  extension  has  been  produced,  change 
in  the  patient's  position  will  not  undo  it.  Nor  will 
uterine  obliquity  produce  a  face  presentation  after  the 
occiput  has  become  well  flexed  and  engaged  in  the 
brim.  It  will  only  do  so  while  the  head  is  above  the 
brim,  and  in  a  position  nearly  intermediate  between 
flexion  and  extension. 

Relation   to   other  complications. — Uterine 

obliquity  is  favoured  by  conditions  which  prevent  the 
bead  from  engaging  in  the  pelvis.  Hence,  uterine 
obliquity  and  pelvic  contraction  often  exist  together  ; 
and  m  do  uterine  obliquity  and  excessive  size  of  the 
child  :  all  conditions  that  favour  face  presentation. 

(d)  The  shape  Of  the  head. — Face  presentation 
has  been  thought  due  to  unusual  length  of  the  head — 
dolicho-cephalus.  There  is  no  doubt  that  in  children 
born  in  face  positions,  the  head  is  longer  than  in  most 
children.  But  this  is  from  moulding  during  labour. 
The  lengthening  does  not  always  go  quite  away  after 
delivery,  and  for  this  reason  it  has  been  thought  that 
it  must  have  been  present  before  labour.  But  de- 
formities of  the  head  produced  by  other  modes  of 
delivery  often  persist  in  a  small  degree  throughout 
life,  and  therefore  the  elongation  produced  by  face 
delivery  may  do  so.  If  the  lengthening  of  the  head 
were  a  peculiarity  in  shape  present  before  labour,  it 
must  be  an  inherited  peculiarity ;  and  if  this  were  so, 
we  should  expect  face  presentations  to  show  a  tendency 
to  recur  over  and  over  again  in  the  same  mother  ;  and 
this  has  not  been  shown  to  be  the  case.  A  few  heads 
have  been  measured,  not  bona  in  face  positions,  in 
which  the  back  of  the  head  was  longer  in  proportion 
than  usual,  and  therefore  its  occasional  occurrence  must 
be  admitted.     Further,  in  heads  so  shaped  that  the 


20  Difficult  Labour. 

hinder  half  i&  the  larger,  the  coronal  and  lambdoidal 
sutures  run  more  backwards  than  usual,  so  that  the 
parietal  bones  are  nearer  the  rhomboidal  than  the 
oblong  shape,  and  the  posterior  inferior  (or  mastoid) 
angle  of  the  parietal  bone  is  larger  than  it  usually  is. 
Hecker  found  that  in  children  born  with  face  presenta- 
tion the  average  magnitude  of  this  angle  was  larger 
than  in  those  born  with  the  vertex  presenting.  This 
is  a  peculiarity  which  could  not  possibly  be  produced 
by  moulding  during  delivery.  I  think,  therefore,  that 
while  lengthening  of  the  head  in  face  presentations  is 
often  entirely  due  to  moulding,  and  is  generally  in- 
creased by  it,  yet  it  is  not  always  due  to  it,  and  has 
Borne  influence  in  the  production  of  face  presentations. 
Mode  of  action. — It  is  said  that  when  the  head  is 
too  long,  the  part  behind  the  occipito-spinal  joint  is  as 
long,  or  longer,  than  the  part  in  front  of  it ;  and  thus, 
one  of  the  mechanical  conditions  that  usually  favour 
flexion  is  absent,  or  the  shape  of  the  head  may  even 
favour  extension. 

2.  Conditions  which  hinder  normal  presenta- 
tion.— The  conditions  which,  by  hindering  normal 
presentation,  favour  malpresentations  of  all  kinds,  face 
included,  are  : — (a)  Excess  of  liquor  amnii. — When 
there  is  so  much  liquor  amnii  that  the  child  floats 
freely  in  it  instead  of  getting  engaged  in  the  pelvic 
brim,  it  may  happen  that  when  the  membranes  break, 
the  child  is  in  such  a  position  that  its  face  comes  down 
into  the  os  uteri.  But  there  is  no  reason  that  we  know 
of  why  the  child's  face  should  under  such  conditions 
be  the  part  to  come  into  the  brim  ;  and  face  presenta- 
tions produced  in  this  way  are  very  rare,  (b)  Dead 
children. — In  the  case  of  decomposing  children,  the 
tonicity  of  the  muscles  which  helps  to  maintain  the 
foetal  spine  bent,  and  to  keep  the  chin  bent,  is  absent, 
and  therefore  extension  is  more  apt  to  occur  than  with 
living  children.  (c)  Twins. — In  twin  pregnancies 
abnormal  presentations  are  common,  because  both 
children  cannot  get  engaged  in  the  brim.  Face  pre- 
sentations are    thus  more   common   than  in  natural 


Treatment  of  Face  Presentations.       21 

labour,  but  they  are  not  more  likely  to  occur  than 
other  malpresentations. 

3.  Rare  conditions  Of  the  fcetUS. — There  are  some 
conditions  of  the  foetus  which  undoubtedly  may  produce 
face  presentations.  Enlargement  of  the  thyroid  gland 
may  form  such  a  lump  in  front  of  the  neck  as  to  prevent- 
the  child  from  bending  its  head.  If  the  cord  be 
rendered  short  by  being  coiled  round  the  child's  neck, 
and  the  child  lies  facing  the  placental  site,  the  neck 
may  be  so  pulled  forward  as  to  extend  the  head.  It 
is  said  that  absolute  shortness  of  the  cord,  without 
coiling,  may  so  pull  the  belly  forward  as  to  extend  the 
head ;  but  such  shortness  as  this  is  excessively  rare, 
if  it  ever  occur.  In  anencephalous  monsters,  in  which 
there  is  no  cranial  vault,  the  face  often  presents. 
Abnormal  rigidity  of  the  extensor  muscles  of  the  neck 
has  been  described  as  a  cause  of  face  presentations. 
This  is  very  rare,  and  we  know  nothing  as  to  why 
it  should  occur.  If  present  it  would  account  for  the 
face  presenting.  Prolapse  of  the  hand  or  foot  by  the 
side  of  the  head  may  prevent  the  vertex  from  engaging 
in  the  brim  and  bring  about  a  face  presentation. 

Treatment  of  face  presentations. — If  it  be 

possible  to  change  the  face  presentation  into  a  vertex, 
this  should  be  done.  But  it  is  not  always  possible. 
It  is  impossible  when  the  head  has  descended  into  the 
pelvic  cavity,  because  during  the  change  of  position 
the  maximum  diameter  of  the  head  must  for  a  time  lie 
aci'oss  the  pelvis.  As  this  diameter  in  a  child  of  average 
size  measures  five  inches  and  a  quarter,  while  the  largest 
diameter  of  j  an  average  pelvis  does  not  exceed  five 
inches,  this  cannot  take  place.  If  the  child  be  so  small 
that  its  maximum  diameter  can  pass  through  the  pelvis, 
labour  will  be  so  easy  that  there  is  no  need  for  inter- 
ference. It  is  impossible  to  change  the  position  when 
the  presentation  is  produced  by  a  condition  of  the  foetus 
which  prevents  flexion.  It  is  practically  impossible 
when  the  presentation  is  produced  by  contraction  of 
the  pelvis  or  the  very  large  size  of  the  child's  head  : 
because  then,  although  it  may  bu  possible  to  get  the 


22  Difficult  Labour. 

vertex  to  present  at  the  brim,  it  will  be  very  difficult 
to  get  it  to  stay  there.  Change  of  position  is  possible, 
but  difficult,  after  rupture  of  the  membranes. 

How  to  change  a  face  presentation  into  a 
vertex. — There  are  two  ways :  one  by  pressing  on 
the  face  and  the  occiput ;  the  other  by  pressing  on  the 
Bhoulders  and  breech. 

1.  Put  two  fingers  in  the  vagina,  and  the  other 
hand  on  the  abdomen.  In  most  cases  the  occiput  can 
be  felt  quite  easily,  separated  from  the  back  by  a  deep 
sulcus.  Press  the  face  up,  either  by  pressure  first  on 
the  jaws,  and  then  on  the  forehead,  and  at  the  same 
time  press  the  occiput  down  (Fig.  13).  If  you  have 
succeeded  in  pressing  the  forehead  above  the  pelvic 
brim,  then  use  both  hands  outside,  with  one  hand 
pressing  the  Occiput  deep  down  into  the  pelvis,  with 
the  other  pressing  the  face  upwards  and  towards  the 
middle  line.  No  harm  will  come  from  trying  to  do 
this,  even  if  it  does  not  succeed. 

2.  The  other  method  (known  as  Schatz's)  is  by 
pressing  the  shoulders  towards  the  dorsal  aspect  of 
the  child,  so  as  to  undo  the  extension  of  the  spine 
which  is  the  accompaniment,  and  sometimes  the 
cause,  of  face  presentation.  Place  the  two  hands 
on  the  abdomen,  get  them  if  possible  below  and  in 
front  of  the  shoulders ;  press  the  shoulders  and  chest 
of  the  child  upwards,  and  to  the  side  to  which  the 
child's  back  is  turned  (Fig.  14).  If  the  child's  back 
is  behind,  at  the  same  time  turn  it  forwards.  If 
you  can  succeed  in  this,  and  have  raised  the  shoulders, 
press  them  up  with  one  hand,  while  with  the  other 
you  press  the  breech  first  in  the  opposite  direction  and 
then  downwards,  so  as  first  to  bend  the  spine  and  then 
press  it  down  (Fig.  15).  If  you  can  succeed  in  un- 
doing the  extension  of  the  spine,  the  downward 
pressure  will  flex  the  head  (Fig.  16).  This  manoeuvre 
is  harmless,  but  may  fail. 

Rules  for  management  of  unreduced  face 

positions. — If  you  have  not  succeeded  in  changing 
the  face  presentation  into  a  vertex,  or  if  you  are  not 


The  Rectifying  of  Face  Presentation.    21 


Fig.  15. 


Fig.  10. 

Fig.  13.— Showing  Mode  of  rectifying  Face  Presentation  by  pressing  tin 

Face  up  and  the  Occiput  down. 

Figs.  14-10.— Showing  Schatz's  Method  of  rectifying  Face  Presentation. 


24  Difficult  Labour. 

called  until  it  is  too  late  to  attempt  it,  the  case  should 
be  managed  according  to  the  following  rules  : — 

1.  Tlie  head  is  above  the  pelvic  brim  ;  the  os  uteri  is 
not  fully  dilated;  the  bag  of  membranes  is  entire.  Do 
nothing,  except  direct  the  patient  to  avoid  everything 
which  is  likely  to  cause  rupture  of  the  membranes. 
The  bag  of  membranes  will  dilate  the  cervix  better 
than  anything  else. 

2.  The  os  uteri  is  not  fully  dilated,  and  the  mem- 
branes are  ruptured.  The  face  with  each  pain  comes 
down  and  engages  in  the  os,  putting  it  on  the  stretch. 
Let  it  alone :  the  face  will  dilate  the  os  better  than 
any  artificial  means. 

3.  The  membranes  are  ruptured,  but  the  head  is  not 
coming  down  into  the  os  to  dilate  it;  it  is  detained 
above  the  brim.  Probably  either  the  pelvis  is  con- 
tracted or  the  head  is  too  large.  If  the  os  will 
admit  the  hand,  perform  podalic  version,  bringing 
down  one  leg.  If  it  will  not,  act  according  to  the 
condition  of  the  patient.  If  the  pains  are  infrequent 
and  the  pulse  slow,  wait  till  the  os  will  admit  the 
hand.  If  the  pains  are  frequent,  the  patient  getting 
tired,  and  the  dilatation  being  evidently  retarded  by 
the  absence  of  any  dilating  agent,  put  in  Champetier 
de  Ribes's  dilating  bag,  and  when  this  has  dilated  the 
os  uteri,  bring  down  a  foot  and  deliver. 

4.  The  os  is  fully  dilated,  the  head  is  in  the  pelvic 
cavity,  the  chin  is  in  front,  the  second  stage  has  not 
lasted  two  hours.  Leave  the  case  to  nature.  If, 
regular  and  frequent  pains  being  present,  the  head  is 
not  delivered  within  two  hours,  help  delivery  with 
forceps. 

5.  The  os  is  fully  dilated,  the  head  sunk  low  in  the 
pelvic  cavity,  but  the  chin  is  behind.  If  the  second 
stage  has  not  lasted  two  hours,  leave  the  case  alone, 
in  the  expectation  that  the  chin  will  rotate  to  the 
front  (Fig.  17).  If  within  two  hours,  after  full  dilata- 
tion of  the  os,  notwithstanding  regular  and  frequent 
pains,  the  chin  has  not  turned  forwards,  turn  it  to  the 
front,  and  deliver  with  forceps.     Put  the  left  hand  in 


Face  Presentations. 


25 


the  vagina,  the  right  hand  on  the  abdomen.  Grasp 
the  face  with  the  thumb  and  four  fingers.  Turn  it 
round  by  the  shortest  route  so  as  to  bring  the  chin 
to  the  front  (Fig.  18).  At  the  same  time,  with  the 
hand  on  the  abdomen,  press  the  anterior  shoulder  in 


Fig.  17. — Face  sunk  down  into  Pelvis  with  Chin  behind :  wedge-like  block- 
ing of  brim  of  pelvis  by  cranium  and  chest.    (After  R.  Barnes.) 

*bc,  Wedge  formed  by  head  and  upper  part  of  chest.     (N.B.  This  can  only 
bappen  with  a  small  child.) 


the  same  direction.  If  the  chin  points  directly  back- 
wards, observe  in  which  oblique  diameter  the  shoulders 
lie,  and  move  the  chin  in  the  same  direction  as  that 
in  which  you  press  the  anterior  shoulder  to  get  it  to 
the  front.  When  you  have  brought  the  chin  to  the 
front,  apply  forceps  and  deliver. 

If  by  the  measures  described  in  the  foregoing 
paragraphs  delivery  cannot  be  accomplished,  per- 
foration is  the  only  resource. 


26  Difficult  Labour. 

BrOW  presentations. — If  the  mechanical  con- 
ditions which  produce  extension  of  the  head  have  not 
had  their  full  effect  (so  as  to  produce  a  face  presentation), 
the  head  may  be  incompletely  extended,  and  so  present 
with  the  brow.  In  this  position  the  middle  of  the 
frontal  suture,  or  a  point  near  it,  lies  over  the  os  uteri, 
and  the  points  opposed  to  the  pelvic  walls  are  the 
lower  jaw  on  one  side  and  a  point  near  the  middle  of 
the    sagittal    suture   on  the    other.      The    maximum 


Pig.  18. — Showing  Rotation  of  Chin  forwards  which  should  take  place  when 
the  Chin  is  behind.    {After  Farabeuf.) 

diameter,  the  mento-vertical,  or  one  as  near  it  as  the 
size  of  the  pelvis  will  admit,  is  engaged  in  the  brim, 
and  has  to  pass  through  the  pelvis  if  the  head  is  to  be 
born  in  this  position.  Now  as  the  maximum  diameter 
of  the  head  averages  five  inches  and  a  quarter,  while 
the  largest  diameter  of  the  pelvic  cavity  only  averages 
five  inches,  it  is  clear  that  it  is  not  possible  for  a  child 
of  average  dimensions  to  pass  through  the  pelvis  in 
this  position,  unless  the  head  is  greatly  moulded,  so 
that  its  maximum  diameter  is  considerably  reduced. 

Sometimes  this  happens.     The  head  is  driven  down 
into  the  pelvis  with  the  brow  in  advance.     The  jaw 


Treatment  of  Brow  Presentations.      27 

(not  the  forehead,  as  in  occipito-posterior  cases)  is  fixed 
behind  the  pubes,  and  the  head  rotates  round  the  jaw- 
as  a  centre,  th.B  whole  length  of  the  sagittal  suture, 
but  especially  its  posterior  half,  being  powerfully 
compressed  and  flattened  down  towards  the  neck,  as 
the  head  passes  through  the  pelvic  outlet.  The  head 
may  also  be  delivered  with  the  jaw  behind,  the  parietal 
bones  being  flattened  behind  the  pubic  symphysis. 
Delivery  in  the  brow  position  is  slow,  and  requires 
great  force  :  either  powerful  uterine  action,  or  uterine 
action  aided  by  powerful  pulling  with  forceps.  Natural 
delivery  is  generally  impossible. 

Treatment. — 1.  The  first  thing  is  to  change  the 
brow  presentation,  if  possible,  either  into  a  vertex  or  a 
face  presentation.  Before  rupture  of  the  membranes, 
employ  the  same  external  manoeuvres  to  undo  exten- 
sion as  have  been  recommended  for  face  presenta- 
tion. If  these  fail,  and  the  membranes  have  ruptured, 
push  up  the  forehead,  and  thus  try  to  get  the  head  flexed. 
If  you  cannot  do  this,  push  up  the  occiput,  so  as  to  try 
and  get  the  chin  down.  The  effect  of  upward  pressure 
will  be  helped  by  letting  the  woman  lie  on  the  side 
opposite  to  which  lies  the  part  that  you  wish  to 
descend.  This  will  favour  uterine  obliquity  towards 
the  side  on  which  the  patient  is  lying ;  and  if  the 
uterus  become  oblique,  its  action  will  have  a  greater 
tendency  to  push  down  the  end  of  the  foetal  head 
towards  which  the  line  of  uterine  action  points. 
These  manoeuvres  are  harmless.  The  objection  to 
them  is  that  they  often  fail.  Brow  presentation,  like 
face  presentation,  is  often  the  result  of  causes  that 
lead  to  extension  of  the  head,  and  so  long  as  these 
causes  continue  to  act,  the  brow  presentation  will  be 
reproduced  as  soon  as  the  upward  pressure  is  left  off. 
Consider  now  what  to  do  if  your  attempt  to  change 
the  brow  position  into  one  of  the  face  or  vertex  fail. 

2.  If  the  head  is  above  the  brim,  the  os  uteri  fully, 
or  nearly  fully,  dilated,  and  in  the  intervals  between 
the  pains  the  uterus  relaxed,  the  best  practice  is  to 
turn,  and  bring  down  one  foot. 


88  Difficult  Labour. 

By  turning  you  ensure  that'  the  head  enters  the 
brim  in  a  favourable  position.  You  incur  the  danger 
of  foetal  death  from  pressure  on  the  cord,  but  this  risk 
is  preferable  to  that  which  mother  and  child  will 
incur  from  protracted  labour  if  you  leave  the  head  in 
its  very  unfavourable  position. 

3.  If  the  head  has  been  driven  down  into  the  pelvic 
cavity,  and  is  there  arrested,  and  the  uterus  is  acting 
vigorously,  it  will  be  impossible,  without  great  risk  to 
the  mother,  to  force  the  head  up  out  of  the  pelvis  and 
get  a  foot  down.  If  the  pains  have  not  been  unusually 
strong,  and  the  second  stage  of  labour  has  not  lasted 
long,  and  yet  the'  head  has  advanced  into  the  cavity, 
the  probability  is  that  the  child  is  not  very  large,  and 
that  you  will  be  able  to  deliver  with  forceps.  There- 
fore, apply  forceps  and  pull.  If  the  pains  are  very 
vigorous,  and  the  second  stage  has  lasted  more  than 
two  hours,  you  will  very  likely  fail.  If  after  a  good 
pull  with  forceps  you  have  not  made  the  head  advance, 
perforate. 

If  the  uterus  has  passed  into  a  state  of  tonic  con- 
traction, and  the  head  is  still  above  the  brim,  do  not 
run  the  risk  of  rupturing  the  uterus  by  trying  to  turn, 
nor  waste  time  and  the  mother's  strength  by  a  fruitless 
effort  at  forceps  delivery,  but  perforate  at  once.  If 
the  head  is  low  down  in  the  pelvic  cavity,  try  forceps, 
but  if  you  cannot  deliver  Quickly,  perforate. 


29 


CHAPTER    IV. 

THE    MOULDING   OF   THE    HEAD. 

It  has  been  mentioned  in  the  foregoing  pages  that, 
in  difficult  labour,  the  head  becomes  moulded.  Con- 
sider now  the  ways  in  which  it  is  moulded  in  the 
different  positions. 

The  moulding  of  the  head. — In  any  head  first 
labour  that  is  at  all  difficult,  the  long  squeeze  that 
the  head  suffers  in  passing  through  the  pelvis  alters 
its  shape.  This  change  in  shape  is  partly  undone 
during  the  first  day  or  two  by  the  elasticity  of  the 
bones ;  but  if  great,  is  never  entirely  lost.  In  the 
different  positions,  the  direction  of  the  greatest  squeeze 
is  different,  and  hence  the  shape  of  the  head  often 
tells  the  way  in  which  a  person  came  into  the  world. 
In  the  following  descriptions  I  only  mention  the 
changes  that  are  characteristic. 

Vertex  presentations,  occipitoanterior.— In 

the  vertex  positions  with  the  occiput  in  front,  the 
sub-occipito-frontal  diameter  is  the  one  most  com- 
pressed. The  frontal  and  occipital  bones  are  over- 
lapped by  the  parietal  bones,  and  the  posterior-lying 
parietal  bone  overlapped  by  the  anterior.  The  squeez- 
ing force  is  applied  to  the  nape  of  the  neck  and  the 
frontal  bone  (Fig.  19).  Hence  the  head  is  elongated 
in  the  mento-vertical  direction,  and  the  forehead  is 
made  to  retreat.  A  long  head  with  a  somewhat 
retreating  forehead  is  the  result. 

OccipitO-posterior. — In  vertex  presentations  with 
the  occiput  remaining  behind,  the  squeeze  is  applied  to 
the  forehead  in  front  and  the  occiput  behind  :  the 
head  is  compressed  in  the  occipito-frontal  diameter 
(Fig.  20).  Hence  this  head,  looked  at  from  the  side, 
is  squarer  than  usual ;  the  forehead  rises  up  steeply 
in  a  line  with  the  face,  and  the  occiput  rises  steeply 


3© 


Difficult  Labour. 


Fig.  19.— Diagram  showing  the  Direction  of  greatest  Squeeze  in  Delivery 
with  Vertex  in  advance  and  Occiput  in  front ;  head  compressed  in 
sub-occipito-frontal  diameter. 

in  a  line  with  the  back  of  the  neck.  The  height  of 
the  top  of  the  cranium  above  the  ears  is  increased. 
But   in   some   cases,    although   the   occiput   remains 


Fig.  20.— Diagram  showing  the  Direction  of  greatest  Squeeze  in  Delivery 
with  Vertex  in  advance  and  Occiput  behind :  head  compressed  in 
occi  pi  to-frontal  diameter. 


Moulding  of  the  Head. 


3i 


21.— Diagram  showing  the  Direction  of  greatest  Squeeze  In  Delivery 
with  the  Face  presenting :  head  compressed  in  cervico-vertical 
diameter. 


behind,  there  is  such  extreme  flexion  that  the 
anterior  fontanelle,  or  a  point,  near  it  gets  behind 
the  symphysis.  The  head  is  then  compressed  in  the 
sub -occipito- frontal,  or  even  sub-occipito-bregmatio 


Fig  22. — Drawing  of  an  actual  Skull  after  Delivery  with  the  Face  in 
advance.    {After  Fritsch.) 


3« 


Difficult  Labour. 


Fig.  23.— Diagram  showing  Direction  of  greatest  Squeeze  in  Delivery  in 
Position  of  Brow  Presentation  :  head  compressed  in  vertico-inental 
diameter. 

diameter,    and  presents   a  high  degree  of  the  same 
kind  of  moulding  as  takes  place  in  occipito-anterior 


Fig.  24.— Drawing  of  an  actual  Skull  after  Delivery  in  Position  of  Brow 
Presentation.    {After  Kiistner., 


Moulding  of  the  Head.  33 

deliveries.  The  moulding  is  great,  because,  owing  to 
the  difficulty  of  delivery,  compression  lasts  long. 
I  imagine  that  as  the  occiput  is  driven  down  the 
forehead  slips  up,  from  the  flexion  produced  by  the 
application  of  the  driving  force,  acting  through  the 
foetal  spine,  behind  the  centre  of  the  head  ;  but  I 
know  not  that  the  mechanism  has  been  observed. 

Face  presentations. — When  the  head  is  delivered 
face  first,  the  front  of  the  neck  is  fixed  against  the 
anterior  pelvic  wall,  and  the  two  parietal  bones 
are  pressed  down  against  the  neck  and  shoulders. 
Hence  the  head  is  elongated  in  the  mento-occipital 
direction.  But  instead  of  the  frontal  bone  being  the 
one  chiefly  squeezed,  as  in  vertex  presentations,  the 
squeezing  is  applied  all  along  the  sagittal  suture 
(Fig.  21).  The  cervico- vertical  diameter  is  the  one 
most  compressed.  Hence  the  forehead  is  not  retreat- 
ing, but  the  head  is  lengthened  and  the  top  of  the 
head  flattened  all  the  way  along  (Fig.  22). 

Brow  presentations. — When  the  head  is  de- 
livered in  the  brow  position,  the  jaw  is  fixed  behind  the 
symphysis.  The  maximum  diameter,  the  men  to-vertical, 
is  brought  into  the  antero-posterior  diameter  of  the 
pelvic  outlet ;  and  the  head  can  only  get  out  by 
compression  of  this  diameter  (Fig.  23).  Hence  the 
head  delivered  in  the  brow  position  has  the  forehead 
running  straight  up.  and  the  line  of  the  sagittal 
suture  running  down  flat  to  the  occiput,  which  is 
lower  than  usual  (Fig.  24). 


i> — :}() 


34 


CHAPTER   V. 

PELVIC    PRESENTATIONS. 

Kinds  of  pelvic    presentations.— When  the 

pelvic  end  of  the  child  presents,  (1)  the  thighs  may 
be  bent  up  close  to  the  abdomen,  and  the  knees  bent 
so  that  the  heels  are  close  to  the  buttocks  This  is 
the  best  position,  because  in  this  position  of  the  legs 
the  pelvic  end  of  the  foetus  is  larger,  and  dilates  the 
passage  more.  (2)  The  legs  may  be  extended,  so  that 
the  feet  are  near  the  head.  (3)  One  or  both  feet  or 
knees  may  come  down  and  present  at  the  os,  or  come 
down  through  it  into  the  vagina.  In  essential  points 
the  management  of  delivery  is  the  same,  although  each 
different  form  of  pelvic  presentation  brings  with  it  a 
liability  to  special  forms  of  difficulty. 

Causes. — Foot  and  knee  presentations  are  apt  to 
occur  rather  than  breech,  when  the  position  of  the 
foetus  was  at  fhe  beginning  of  labour  oblique.  In  an 
oblique  position  of  the  child  it  depends  upon  which 
pole  of  the  foetal  ovoid  lies  the  higher,  whether  the 
arm  or  the  foot  comes  down.  If  the  head  end  is  lower, 
the  shoulder  presents  and  an  arm  comes  down.  If  the 
breech  end  is  lower,  the  breech  occupies  an  iliac  fossa, 
and  probably  a  foot  or  knee  will  present  (Fig.  25). 
Therefore  the  causes  which  favour  transverse  pre- 
sentations also  favour  knee  and  footling  presentations. 
In  contracted  pelvis  foot  presentation  is  more  common 
than  breech. 

Pelvic  presentations  are  frequent  with  premature 
and  dead  children,  because  in  them  the  specific  gravity 
of  different  parts  of  the  foetus  is  altered,  so  that  gravity 
no  longer  steadily  favours  the  presentation  of  the  head. 
About  one  in  five  premature  children  present  by  the 
breech. 

Pelvic    presentations   are    favoured    also    by    all 


Causes  of  Pelvic  Presentations. 


35 


conditions  which  prevent  the  head  from  being  engaged 
in  the  pelvis  ;  among  these  are  too  much  liquor  amnii, 
which  gives  the  foetus  too  much  liberty  to  move, 
and  contracted  pelvis,  which  prevents  the  head  from 
getting  into  the  pelvis.  Pelvic  presentations  occur 
in  about  three  per  cent,  of  labours  with  normal 
pelvis,  and  about  twice  as  often  in  labours  with 
contracted  pelvis. 

In  twin  pregnancy 
breech  presentation  is 
common,  for  the  evi- 
dent reason  that  two 
children  are  more 
easily  accommodated 
in  utero  if  the  large 
end  of  one  fits  oppo- 
site the  small  end  of 
the  other.  Of  twins, 
about  a  quarter  pre- 
sent with  the  breech. 

The  more  widely 
the    conditions    upon 
which    the   presenta- 
tion  depends    depart 
from  the  normal,  the 
more  they  tend  to  pro- 
duce  footling   rather 
than  breech  presenta- 
tions ;    for  the  conditions  which,  when  the  head  is 
lying  lowest,  favour  its  engagement  in  the  brim,  if 
the  pelvic  end  lie  lowest,  favour  the  engagement  of 
the  breech  in  the  pelvis. 

Prognosis  in  breech  presentations. — Taking 
the  average  of  all  cases  together,  statistics  show  that 
labour  with  breech  presentation  is  shorter  than  labour 
with  the  head  presenting.  The  comparative  average 
shortness  of  labours  with  pelvic  presentations  is  because 
every  collection  of  such  cases  comprises  a  large  number 
of  premature  children.  Taking  only  labours  at  term, 
breech  labours  are  on  an  average  a  trifle  longer  than 


Fig.  25. — Diagram  showing  how  Obliquity 
of  the  Uterus  produces  Footling  Pre. 
sentation.     (After  Kiistner.) 


36  Difficult  Labour. 

head  first  labours.  The  prolongation  of  labour  occurs 
chiefly  in  first  labours,  and  in  the  second  stage ;  the 
breech  does  not  stretch  open  the  soft  parts  of  the 
pelvic  floor  so  well  as  the  head.  In  the  first  stage  of 
labour,  and  in  the  second  stage  of  labour  when  tho 
patient  is  not  a  primipara,  there  is  but  little  difference. 

Injuries  to  the  maternal  parts — the  perineum,  vagina, 
and  cervix  uteri — are  less  likely  to  happen  in  breech 
presentations  that  are  let  alone  than  in  head  presenta- 
tions, because  in  the  former  the  soft  parts  are  dilated 
more  gradually.  They  are  not  found  less  frequent  in 
actual  practice,  because  they  are  often  produced  by 
manipulations  designed  to  assist  delivery.  If  the  head 
is  detained  by  the  imperfectly  dilated  cervix,  laceration 
of  the  cervix  will  be  a  probable  result  of  hasty 
delivery. 

Dangers  to  the  Child. — The  prognosis  for  the 
child  is  distinctly  worse  than  in  head  presentations. 
At  least  1  in  10  are  still-born  ;  probably  about  1  in  7  ; 
in  some  charities  as  many  as  1  in  3.  The  difference 
depends  upon  skill  in  management.  Foetal  death  takes 
place  : 

1.  From  pressure  on  cord. — The  death  is  due  to 
asphyxia,  from  the  stoppage  of  the  circulation  by 
pressure  on  the  cord.  This  pressure  is  not  great 
enough  to  be  hurtful  while  the  trunk  is  entering  the 
genital  passage.  But  when  the  child  is  born  as  far  as 
the  navel,  then  the  genital  canal  is  filled  first  with  the 
chest  and  arms,  and  then  with  the  head  of  the  child ; 
and  the  cord  is  compressed  between  them  and  the 
pelvic  wall.  As  the  head  is  hardest,  and  most  com- 
pletely fills  the  canal,  pressing  uniformly  on  it  all 
round,  the  pressure  is  most  dangerous  when  the  head 
is  engaged  in  the  pelvis.  The  larger  the  child  the 
earlier  will  the  pressure  on  the  cord  reach  a  dangerous 
degree.  The  danger  is  greatest  in  foot  presentations ; 
least  when  the  breech  presents  and  the  knees  are  bent, 
for  in  the  latter  case  the  cord  may  lie  protected  by 
the  legs. 

2.  From  premature  inspiration. — There  is  another 


Management  of  Breech  Labours.         37 

way  in  which  death  from  asphyxia  is  likely  to  happen, 
and  some  think  it  happens  oftener  from  this  cause 
than  from  pressure  on  the  cord.  The  contact  with  the 
cold  air  of  the  skin  of  the  part  of  the  foetus  that  is 
born  provokes  inspiration,  and  as  the  mouth  and  nose 
are  still  in  the  passage,  instead  of  air  being  inspired, 
mucus  is  sucked  in,  which  clogs  the  air-passages  of 
the  child  and  suffocates  it. 

3.  From  separation  of  placenta. — Another  reason 
is  given  why  the  child  is  in  peril,  which  is,  that 
the  diminution  in  size  of  the  uterus  lessens  the 
supply  of  maternal  blood,  and  therefore  of  oxygen,  to 
the  placenta,  and  even  that  it  separates  the  placenta  ; 
and  thus  foetal  asphyxia  is  the  result.  This  is  theory. 
It  may  be  true,  but  has  not  been  proved.  It  is  quite 
certain  that  the  uterus  may  be  quite  empty  and  con- 
tracted without  separating  the  placenta ;  much  less 
then  does  contraction  only  to  the  limit  which  the 
presence  of  the  foetal  head  in  the  uterus  allows, 
necessarily  involve  separation  of  the  placenta.  There 
is  no  proof  that  the  supply  of  maternal  blood  to  the 
placenta  is  lessened  when  the  uterus  gets  smaller ;  or 
if  lessened,  that  it  is  lessened  to  a  degree  which  en- 
dangers the  child. 

Management  of  breech  presentations :  first 

Stage. — If  the  membranes  are  unruptured,  do  not 
interfere  in  any  way  with  the  mechanical  conditions 
present.  The  bag  of  waters  will  dilate  the  cervix 
better  than  anything  else.  Keep  the  membranes  un- 
ruptured as  long  as  you  possibly  can.  If  the  bag  of 
waters  appeal's  at  the  vulva,  in  this  case  so  much  the 
better.  The  passages  will  be  well  dilated,  the  circula- 
tion through  the  cord  will  be  maintained,  and  the 
head  will  be  easily  delivered. 

If  the  membranes  rupture  before  full  dilatation  of 
the  os,  there  may  be  difficulty  in  the  birth  of  the  head, 
for  the  following  reason.  The  trunk,  being  smaller 
than  the  head,  can  come  through  the  os  before  it  is 
quite  fully  dilated ;  especially  if  the  arms  do  not  de- 
scend folded  on  the  chest.     Then  the  delivery  of  the 


38  Difficult  Labour. 

head  is  retarded,  because  its  base  is  embraced  by  the 
imperfectly  dilated  cervix.  This  kind  of  difficulty  is 
more  likely  to  happen  in  footling  presentations  than 
in  breech.  It  is  commoner  also  in  premature  labours 
than  in  labours  at  term ;  for  in  premature  children 
the  head  is  larger  in  proportion  to  the  body  than  in 
labour  at  term.  It  is  favoured  by  untimely  pulling  : 
for  if  you  pull  on  the  legs  while  the  advance  of  the 
chest  with  the  arms  folded  in  front  of  it  is  hindered 
by  the  smallness  of  the  os  uteri,  you  will  pull  the 
chest  down,  and  the  arms,  if  they  do  not  descend  with 
it,  will  come  to  be  by  the  side  of  the  head. 

If  the  membranes  have  ruptured  before  full  dilata- 
tion of  the  cervix,  do  not  interfere  unless  it  is  clearly 
necessary.  The  best  practice  in  foot  presentation 
here  differs  from  that  in  breech  presentations.  If  the 
feet  present,  the  condition  will  not  be  made  worse  by 
bringing  down  one  foot,  and  as  this  will  give  the  best 
means  of  traction  in  case  of  need,  draw  down  one 
foot,  choosing  the  anterior  if  you  can  feel  both  (Fig. 
26).  But  do  not  do  more  :  do  not  pull  on  it  in  the 
early  part  of  labour. 

If  the  breech  is  presenting,  and  is  pressed  into  the 
os  with  each  pain,  leave  the  case  alone  until  the 
dilatation  of  the  os  is  complete.  The  breech  is  the 
next  best  dilator  to  the  bag  of  membranes  ;  and  after 
dilatation  of  the  os,  will  descend  into  the  pelvis  unless 
either  the  pelvis  is  contracted  or  the  child  very  large. 

Second  stage :  when  to  bring  down  a  leg. — 
Watch  the  progress  of  the  case  carefully,  and  if  the 
breech  does  not  within  an  hour  or  two  after  the  os 
is  fully  dilated  descend  into  the  pelvis,  it  is  either 
(a)  because  the  pelvis  is  contracted,  (b)  the  child 
very  large,  or  (c)  the  pains  very  feeble.  If  the  pains 
are  frequent  and  strong,  examine  carefully  the  size 
of  the  pelvis,  and  forcn  an  opinion  by  abdominal 
palpation  as  to  the  size  of  the  child.  If  (a)  the  pelvis 
be  contracted,  or  if  (b)  the  child  seem  to  be  very 
large,  bring  down  one  leg.  By  postponing  the  bringing 
down  of  the  leg  till  the  second  stage  of  the  labour,  you 


When  to  Bring  Down  a  Leg. 


39 


get  the  advantage  that  the  os  is  better  dilated  by  the 
whole  breech  than  by  the  half  breech.  The  lower 
uterine  segment  will  not  within  an  hour  or  two  after 
dilatation  of  the  os  have  become  so  thinned  as  to 
make  it  dangerous  to  put  the  hand  into  the  uterus. 
If  the  pelvis  is  normal,  and  the  child  not  excessive  in 
size,  the  only  hindrance  that  can  occur  to  the  advance 


Fig.  26.— Bringing  down  one  Foot.    {After  R.  Barnes.) 

of  the  breech  is  from  (c)  the  pains  not  being  strong 
enough.  If  this  is  the  only  cause  of  delay,  such 
additional  force  as  can  be  applied  with  the  fingers  will 
probably  be  enough,  and,  by  leaving  the  legs  in  con- 
tact with  the  abdomen,  you  protect  the  cord. 

If  a  loop  of  the  cord  has  already  come  down,  the 
cord  has  lost  the  protection  which  the  presence  of 
the  bent-up  legs  would  have  given  it,  were  it  in  utero. 
Here,  then,  the  child's  chances  of  life  will  not  be  made 
worse  by  bringing  down  one  leg ;  on  the  contrary, 
they  will  be  improved,  because  you  will  be  better  aide 


40 


Difficult  Labour. 


to  deliver  quickly,  should  the  child's  life  be  in  danger. 
Therefore,  if  the  cord  come  down,  bring  down  one  leg. 
There  are  thus  three  indications  for  bringing  down  a 
leg  early  in  the  second  stage  of  labour  in  a  breech 
case  :  a  large  child,  a  small  pelvis,  prolapse  of  the 
cord. 

HOW  to  bring  down  a  leg. — Give  chloroform  if 
you  have  it  with  you ;  but  it  is  more  important  that 


Fig.  27.— Bringing  down  a  Leg.    {After  R.  Barnes.) 

the  operation  should  be  done  at  the  right  time  (that 
is,  before  all  the  liquor  amnii  has  escaped,  and  the 
uterus  is  contracted  round  the  child)  than  that  the 
patient  should  be  anaesthetised.  Pass  up  your  hand, 
lubricated  with  sublimate  glycerine,  with  its  palm 
towards  the  child's  abdomen.  Use  the  hand  the  palm 
of  which  will  most  naturally  face  the  foetal  abdomen. 
Support  the  uterus  with  the  other  hand  on  the  fundus 
externally.  The  anterior  foot  is  the  one  to  take. 
When  you  reach  the  knee,  press  it  outwards  and 
backwards  :  the  tension  so  caused  of  the  flexor 
muscles  will  tend  to  bend  the  knees.     Pass  your  hand 


Lingering  Breech  Labours.  41 

up  farther,  and  seize  the  ankle  (Fig.  27).  Draw  it 
down  so  as  completely  to  flex  the  knee,  and  then 
extend  the  thigh  and  so  bring  it  out  of  the  uterus. 
Do  not  try  to  pull  it  down  by  pulling  on  any  part  of 
the  limb  except  the  ankle. 

Delay  from  weak  pains  with  breech  presen- 
tations.— Suppose  now  that  the  breech  is  engaged  in 
the  pelvic  cavity,  but  its  progress  is  slow.  The  second 
stage  has  lasted  two  hours,  the  pains  are  regular,  but 
the  perineum  is  so  little  stretched  by  each  pain  that 
delivery  does  not  seem  at  hand.  Abdominal  examina- 
tion shows  that  the  child  is  not  of  excessive  size. 

Is  there  in  such  a  case  any  danger  in  delay? 
There  may  be  great  danger  to  the  child,  for  even 
without  the  breech  descending  into  the  pelvis,  the 
liquor  amnii  will  slowly  drain  away  and  the  uterus 
get  more  and  more  closely  contracted  round  the  child, 
and  the  cord,  if  it  should  encircle  the  child,  or  if  a 
loop  of  it  lie  unprotected  by  the  limbs  between  a 
prominent  part  of  the  child's  body  and  the  uterine 
wall,  may  be  so  compressed  that  The  circulation  stops, 
and  then  oxygenated  blood  cannot  get  to  the  child,  which 
dies  from  asphyxia.  You  can  tell  whether  this  danger  ia 
imminent,  by  auscultating  the  foetal  heart.  The  heart- 
beats get  a  little  quicker  as  the  uterine  contraction 
begins,  but  then,  as  the  pain  reaches  its  height,  get 
slower  than  before  the  pain  began.  There  is  a  little 
quickening  again  as  the  pain  passes  off,  and  then  the 
fcetal  heart-beats  return  to  their  former  frequency. 
If  the  child  is  in  danger,  the  fcetal  heart-beats  first  fail 
to  regain  their  former  frequency  during  the  intervals 
of  pain,  then  they  become  slower  and  intermittent, 
and  at  last  stop.  If  you  find,  then,  that  the  fcetal 
heart  is  slow  between  the  pains,  there  is  need  of 
delivery. 

There  may  be  reason's  of  less  weight  for  giving 
assistance,  arising  from  the  mother's  condition.  There 
is  no  danger  of  pressure  damage,  for  the  breech  is  too 
soft  to  produce  the  sloughing  we  find  from  the  pro- 
longed pressure  of  the  head.     And  if  feeble  pains  are 


43  Difficult  Labour. 

the  sole  cause  of  delay,  the  breech  is  not  pressed  down 
strongly  enough  to  damage  anything.  But  there  are 
disadvantages  in  letting  a  labour  linger  on,  even  though 
there  be  no  immediate  danger  from  pressure ;  for  a 
very  long  labour  exhausts  the  mother,  from  want  of 
sleep,  want  of  food,  pain,  and  anxiety.  Therefore,  while 
we  quite  recognise  that  if  we  wait  the  patient  will  in 
time  be  naturally  delivered,  yet  it  will  be  good  practice 
to  hasten  delivery,  provided  this  be  skilfully  done. 
But  no  attempt  should  be  made  till  the  os  uteri  is 
fully  dilated  and  retracted  above  the  breech. 

Digital  pulling.— In  this  case  (that  of  delay 
simply  from  weakness  of  pains)  gentle,  steady 
traction  will  accomplish  delivery.  Wait  for  a  pain, 
then  pass  up  your  right  forefinger  over  the  anterior 
groin,  between  the  abdomen  and  the  thigh.  Take  the 
anterior  first,  because  it  is  nearest.  Assist  the  pro- 
pulsive action  of  the  uterus  by  pulling  with  the  finger. 
As  soon  as  the  breech  is  low  enough  for  you  to  reach 
the  posterior  groin,  pass  up  the  fore  and  middle  fingers 
of  the  left  hand  over  the  groin.  The  posterior  buttock 
has  to  make  a  longer  journey,  and  encounter  greater 
resistance,  than  the  anterior,  for  it  has  to  travel  in  a 
segment  of  a  larger  circle  round  the  pubes,  and  to 
stretch  the  perineum,  and  therefore  more  pulling  will 
be  needed  to  get  it  down :  and  it  is  less  easy  to  get  a 
good  grasp  of  the  posterior  buttock  than  the  anterior. 
To  counterbalance  these  difficulties,  use  two  fingers  to 
the  posterior  groin.  You  have  now  a  good  grasp  of 
the  breech.  Do  not  pull  at  it  between  the  pains ;  you 
will  find  delivery  very  difficult  without  the  help  of  the 
uterus,  so  that  you  will  only  uselessly  tire  your 
fingers.  If  you  could  get  out  the  child  in  the  absence 
of  uterine  contraction,  you  would  expose  the  patient 
to  great  danger  of  post-partum  haemorrhage.  But 
when  you  feel  the  breech  pressed  down  by  the  uterus, 
then  pull  as  strongly  as  you  can.  As  the  breech 
passes  the  outlet,  pull  mainly  on  the  posterior  hip 
(Fig.  28),  as  this  has  to  move  round  the  symphysis. 
If    the  pelvis   is   of  normal    size,   and   the   child    of 


Difficult  Breech  Delivery. 


43 


average  dimensions,  delivery  by  this  method  will  be 
easy,  and  no  damage  can  result  from  it  beyond  a  little 
stiffness  in  the  operator's  fingers  and  fore-arms. 

But  pains  may  be  vigorous,  the  breech  well  down 
in  the  pelvis,  and  yet  labour  does  not  progress. 
Assuming  that  the  pelvis  is  normal,  the  cause  is  either 
a  big  child  or  else  deformity  such  as  hydrothorax  or 


Pig.  28.— Digital  Traction  on  posterior  Hip.    {After  R.  Barnes.) 


ascites.  These  latter  conditions  cannot  be  found  out 
except  by  the  impossibility  of  getting  the  enlarged 
body  of  the  child  through  the  pelvis. 

Other  modes  of  pulling. — If  the  child  be  not  too 
big,  it  can  be  delivered  by  pulling.  There  are  three 
ways  of  pulling  strongly  : — 

1.  By  bringing  down  a  leg. — It  has  already  been 
urged  that  the  diagnosis  of  a  small  pelvis  or  a  big 
child  ought  to  be  made  early,  and  if  either  be 
present   a    leg   ought  to   be     brought   down   at   the 


44  Difficult  Labour. 

beginning  of  the  second  stage.  But  if  the  diagnosis 
is  not  made  early,  and  the  need  for  help  is  only 
discovered  when  the  uterus  is  closely  contracted  round 
the  child,  it  will  be  very  difficult  to  bring  down  a  leg ; 
and  if  the  obstruction  be  so  great  that  the  lower 
uterine  segment  is  getting  thinned,  it  will  be  dangerous 
to  try.  In  such  circumstances,  therefore,  do  not  try 
to  get  down  a  leg,  but  pull  on  the  breech.  You  may 
do  this  by 

2.  The  fillet. — This  may  be  a  silk  handkerchief, 
which  is  soft  and  strong.  Some  accoucheurs  carry  a 
piece  of  strong  webbing  in  the  bag  for  this  purpose ; 
a  piece  of  indiarubber  tubing  about  two  feet 
long  with  strong  whipcord  inside  it  has  been 
suggested.  The  handkerchief,  or  the  cord,  or  what- 
ever is  used,  after  being  boiled,  is  passed  with  one 
finger  or  two  fingers  over  the  groin,  and  then  seized 
with  two  fingers  of  the  other  hand  ;  and  thus  a  loop 
is  formed  by  which  the  breech  can  be  pulled 
onwards  with  as  much  force  as  the  material  of  the 
loop  will  bear.  It  has  been  recommended  that  one 
end  of  the  loop  be  passed  from  without  inwards  over 
each  thigh,  and  the  two  ends  brought  down  between 
the  thighs,  thus  putting  a  girdle  round  the  pelvis. 
This  is  an  excellent  way  of  getting  a  hold  on  the 
child  ;  but  it  takes  longer,  and  it  is  more  difficult  to 
apply  a  loop  over  each  thigh  than  only  over  one. 
Whatever  the  way  in  which  it  is  applied,  the  loop 
has  the  advantage  that  the  only  harm  done  by  it  is 
the  pressure  it  directly  exerts  on  the  child ;  and  it 
is  effective. 

3.  The  blunt  hook. — There  is  an  easier  way  viz. 
the  blunt  hook.  It  is  easier  to  apply  this  than  to  pass 
a  fillet  over  the  groin.  Take  the  hook  in  your  right 
hand.  Pass  the  first  two  fingers  of  the  left  hand  up 
in  front  of  the  anterior  groin.  Pass  the  hook  up 
between  the  child's  body  and  your  protecting  fingers, 
the  plane  of  its  curve  close  to  your  fingers.  When 
its  point  is  above  the  fold  of  the  groin,  turn  its 
point  in  between  the  thigh  and  the  abdomen,  and  then 


Use  of  the  Blunt  Hook. 


45 


thigh 


lower  the  hook,  so  that  the  groin  may  fill  its  concavity. 
Now  pass  two  fingers  of  the  left  hand  between  the 
thighs  of  the  child,  and  feel  for  the  point  of  the  hook. 
By  movements  of  the  right 
hand,    guided   by   the   in- 
formation acquired  by  the 
left  hand,  adjust  the  point 
of  the  hook  so  that  it  shall 
not   press    either    on    the 
genitals  or  on  the    thigh, 
but  be  free  between  the 
and  the  genital  parts. 

The  blunt  hook  is  the  easiest 
way  of  pulling  powerfully  on  the 
breech.  It  is  the  best  means  of 
delivery  in  really  difficult  cases. 
The  objection  to  it  is,  that  if  it 
be  used  without  due  care,  or  if 
too  small  a  hook  be  used,  the 
end  of  the  hook  may  injure  the 
child ;  may  lacerate  the  thigh, 
wound  the  femoral  vessels,  or 
damage  the  genitals.  But  with 
care  these  accidents  can  be 
avoided.  If  the  child  is  known 
to  be  dead,  the  blunt  hook  can  be 
used  without  fear ;  and  in  a  case 
of  breech  delivery  in  which  the 
difficulty  is  really  great,  and  is 
due  to  disproportion  between 
the  child  and  the  pelvis,  it  is 
so  likely  that  the  child  is  dead 
that  the  fear  of  possible  injury 
need  not  be  long  influential  in 
preventing  you  from  taking  up 
the  blunt  hook. 

Many  blunt  hooks  sold  in  the  shops  are  too  small 
to  be  safely  used  with  a  big  child,  and  it  is  for  big 
children  that  you  are  likely  to  want  the  hook.  The 
internal  diameter  of  the  curve  of  the  hook  ought  to  be 


Fig.  29.— Blunt  Hook. 


46  Difficult  Labour. 

at  least  two  inches,  and  had  better  be  two  inches  and 
a  quarter  (Fig.  29).  The  handle  should  be  transverse, 
and  the  whole  instrument  made  of  metal,  so  that  it 
can  be  boiled  when  it  has  to  be  disinfected. 

Forceps  for  the  breech. — It  has  been  recom- 
mended to  use  the  ordinary  obstetric  forceps  to  seize 
and  pull  down  the  breech.  Special  forceps  have  also 
been  constructed  with  which  to  do  this.  The  ordinary 
forceps  is  not  suited  for  the  purpose,  and  the  special 
forms  are  less  efficient  in  grasp,  and  more  likely  to  do 
harm  than  the  blunt  hook.  Therefore,  have  nothing 
to  do  with  forceps  for  the  breech. 

Delivery  Of  the  arms. — When  the  trunk  and 
legs  have  emerged,  wrap  them  in  a  napkin,  then 
deliver  the  arms.  Now  begins  the  danger  for  the  child. 
If  the  arms  and  head  are  not  quickly  delivered,  the 
child  will  die  from  asphyxia  from  pressure  on  the  cord. 

You  are  generally  told  to  draw  down  a  loop  of  the 
cord,  but  I  do  not  know  why ;  nothing  is  gained  by 
doing  so,  except  that  you  then  know  the  cord  is  not 
too  short.  You  are  told  also  to  put  the  cord  where 
there  is  most  room.  If  the  pelvis  is  so  shaped  that 
you  can  at  once  perceive  that  the  resistance  is  in  one 
diameter,  and  there  is  plenty  of  room  in  another,  and 
you  can  place  the  cord  where  there  is  room,  do  it ;  the 
advantage  is  evident ;  but  such  cases  are  rare.  It  is 
generally  better  to  deliver  at  once,  than  to  waste  time 
in  trying  first  to  find  out  where  pressure  is  least,  and 
then  to  put  the  cord  there. 

"Wrap  the  child's  body  in  a  napkin,  and  have  it  held 
forwards  by  an  assistant,  out  of  the  way.  Then  pass 
the  hand  along  the  front  of  the  child's  chest,  to  feel 
for  the  arms.  If  they  are  in  their  proper  place,  you 
will  feel  them,  and  all  you  have  to  do  is  to  hitch  a 
finger  first  in  one  elbow,  then  in  the  other,  and  pull 
each  clown. 

Bringing  down  the  arms. — If  the  arms  are 

extended  by  the  sides  of  the  head,  their  delivery  is 
sometimes  very  difficult.  Grasp  the  child's  body  so 
that  you  hold  it  by  the  bony  ring  of  the  pelvis  (thus 


Bringing  Down  the  Arms. 


47 


avoiding  injury  to  the  viscera  from  the  pressure 
of  your  fingers),  and  draw  it  down,  so  as  to  get 
the  arms  as  neai'ly  within  reach  as  possible.  It  is 
generally  recommended  to  bring  down  first  the  arm 
which  lies  behind,  on  the  ground  that  there  is  more 


Fig.  30.— Bringing  down  the  Arms.    (After  Fardbevf.) 

room  in  the  hollow  of  the  sacrum.  But  it  is  not 
very  important  which  you  take  first.  Sometimes  you 
will  find  the  anterior  arm  easier  to  get,  because  it  is 
nearer.  Pass  up  the  hand  corresponding  to  the  arm 
you  are  going  to  bring  down,  along  the  side  of  the 
child,  nearer  its  dorsal  than  its  abdominal  aspect,  and 
then  alongthearm,  until  your  finger  tips  have  reached  the 
elbow  (Fig.  30).    Now  place  the  fore  and  middle  fingers 


48  Difficult  Labour. 

along  the  child's  humerus,  that  they  may  protect  it 
like  a  splint,  and  with  the  tips  of  the  fingers  press  the 
elbow  down  across  the  child's  face.  Continental 
accoucheurs  recommend  that  while  doing  this,  and 
especially  in  liberating  the  anterior  arm,  the  child's 
body  should  be  turned  so  that  the  arm  should  come 
down  in  the  hollow  of  the  sacrum.  But  this  is  not  of 
importance,  and  is  less  easily  done  in  the  left  lateral 
position  adopted  in  Great  Britain  than  in  the  dorsal 
position  customary  abroad.  The  bringing  down  of  the 
aims  is  often  very  difficult,  and  should  be  done  with 
the  greatest  gentleness  and  care. 

There  is  a  rare  condition  which  causes  great 
difficulty,  viz.  dorsal  displacement  of  the  arm.  This 
means,  that  the  arm  is  extended  by  the  side  of  the 
head,  and  the  elbow  bent,  so  that  the  fore-arm  lies 
behind  the  neck.  As  the  head  descends,  the  fore-arm 
is  apt  to  catch  on  the  brim,  and  unless  the  child  be 
small,  or  the  pelvis  very  large,  to  arrest  the  advance 
of  the  head. 

There  are  two  ways  in  which  this  displacement 
may  occur.  It  is  likely  to  be  produced  if  you  try 
to  turn  the  trunk  or  head,  instead  of  letting  it  be 
gradually  turned  by  the  resistance  of  the  pelvic  floor. 
Just  as  when  you  pull  the  body  down  too  soon  the 
arms  are  likely  to  remain  up,  so  if  you  too  hastily 
turn  the  body  round  the  arms  may  not  turn  with  it. 
Then,  when  the  arm  has  thus  got  behind  the  head  and 
the  head  is  pushed  or  pulled  down,  the  arm  is  carried 
down  by  the  occiput  behind  the  nape  of  the  neck 
(Fig.  31). 

This  cause  of  delay  will  be  discovered  when  you 
pass  your  hand  up  to  bring  down  the  arms.  To  undo 
the  displacement,  you  must  rotate  the  child  in  the 
opposite  direction  to  the  rotation  which  produced  the 
displacement ;  press  the  vertex  towards  the  opposite 
arm  to  the  one  which  is  behind  the  neck. 

This  is  one  way :  the  displacement  taking  place 
from  above  downwards ;  the  arm  being  first  extended, 
and    then    the    fore-arm    carried    down.       Extension 


Dorsal  Displacement  of  Arm. 


4§ 


of  the  arm  carries  the  scapula  away  from  the  spine 
so  that  its  outer  edge  forms  the  posterior  wall  of 
the  axilla.  Dorsal  displacement  of  the  arm  has 
also  been  noticed  as   taking  place  in   another  way, 


Fig.  81.— Dorsal  Displacement  of  Arm.     {After  E.  Barnes.) 

viz.  when  the  arms  are  not  extended,  but  are  lying 
across  the  chest.  It  happens  from  the  same  cause : 
from  rotation  of  the  trunk,  which  the  arms  have  not 
shared.  The  body  turning,  the  arm  is  (in  relation  to 
the  child)  forced  back,  and  then,  as  the  trunk  of  the 
child  is  pulled  downwards,  the  fore-arm  is  carried 
(relatively)  up.  In  this  form,  as  the  arm  was  never 
e— 36 


50  Difficult  Labour. 

extended,  the  scapula  is  close  to  the  spine,  and 
its  outer  edge  cannot  be  felt.  The  position  of  the 
scapula  marks  the  difference  between  these  two  modes 
of  production  of  the  displacement.  In  this  form  the 
treatment  is  to  pass  up  the  hand  along  the  back  of 
the  child,  seize  the  elbow,  and  pull  it  downwards 
and  forwards. 

Delivery  of  the  after-coming  head.— The  next 
business  is  ilie  delivery  of  the  head.  This  (except  in 
unusual  cases  of  pelvic  deformity)  must  be  done 
quickly,  or  else  the  child  will  die  from  asphyxia, 
owing  to  pressure  on  the  cord. 

With  a  normal  pelvis,  an  average-sized  head,  and 
normal  mechanism,  the  greatest  diameter  of  the  foetal 
head  that  has  to  pass  through  the  pelvis  is  half  an 
inch  less  than  the  diameter  of  the  pelvis  through 
which  it  has  to  pass.  There  is,  therefore,  no  obstruc- 
tion to  the  delivery  of  the  head,  except  from  the  soft 
parts.  In  such  a  case  all  that  you  have  to  do  is  to 
gently  pull,  in  a  direction  at  first  downwards,  then 
downwards  and  forwards.  Pull  forwards,  that  the 
nape  of  the  neck  may  closely  hug  the  symphysis,  and 
thus  the  perineum  be  less  stretched.  You  can  pull 
best  by  putting  the  index  and  middle  finger  of  the 
right  hand  on  the  shoulder  of  the  child. 

Suppose  that  from  either  small  size  of  the  pelvis  or 
large  size  of  the  head,  gentle  pulling  at  the  neck  is 
unsuccessful ;  the  head  may  be  detained  either  (a)  above 
the  brim  or  (b)  in  the  pelvic  cavity.  Pelvic  contraction 
usually  leads  to  detention  above  the  brim  (because 
the  flat  pelvis,  in  which  the  narrowing  is  at  the  brim, 
is  the  commonest  kind  of  contracted  pelvis).  Large 
size  of  the  head  commonly  leads  to  detention  in  the 
pelvic  cavity. 

Difficult  delivery. — Consider  first  detention  above 
the  brim.  There  are  three  other  ways  in  which  the 
head  may  be  helped  through  : — 

1.  By  pushing  from  above. 

2.  By  pulling  on  the  jaw. 

3.  By  forceps. 


Delivery  of  after-coming  Head.         51 

These  have  been  variously  combined,  and  different 
ways  of  applying  the  hands  and  fingers  described. 
But  all  the  different  recommendations  resolve  them- 
selves into  these  three  modes. 

Pressure  from  above. — The  first  mode  is  simple. 
Place  both  hands  on  the  abdomen,  over  the  uterus, 
and  press  down  as  hard  as  you  can,  taking  care  that 
the  greatest  pressure  is  exerted  on  the  anterior  part  of 
the  head,  so  that  it  may  favour  flexion.  It  is  a  simple 
matter,  to  place  one's  hands  on  a  patient's  uterus  and 
push,  so  that  you  can  get  the  nurse  to  do  this  while 
you  assist  by  traction  on  the  jaw  or  by  forceps. 

Simple  pressure  from  above  is  not,  in  my  opinion, 
the  best  way  of  delivering  the  after-coming  head.  If 
unskilfully  applied,  the  occiput  may  be  pressed  down, 
and  extension  produced.  But  even  if  skilfully  applied, 
it  has  the  following  disadvantage  :  pressure  from  above 
is  exerted  on  the  top  of  the  head.  It  tends  to  make 
the  vertex  flatter  instead  of  more  pointed,  and  to 
enlarge  the  transverse  diameters  of  the  head,  or  at  least 
to  oppose  their  diminution.  (See  Fig.  86,  page  206.) 
Hence,  employed  alone,  it  is  not  a  method  which 
gives  a  result  in  proportion  to  the  force  expended,  and 
is  not  a  good  mode  of  aiding  delivery,  although 
applied  to  the  front  of  the  head  it  may  assist  flexion. 
The  best  use  of  pressure  from  above  is  to  make  it 
assist  traction  from  below. 

Jaw  traction. — Deli  very  by  pulling  with  the  finger 
in  the  mouth  was  taught  by  Smellie,*  and  is  called  by 
his  name  (associated  in  French  and  German  text-books 
respectively,  with  the  name  of  the  French  or  German 
obstetrician  who  introduced  it  in  those  countries). 
Unfortunately  for  his  reputation,  after  recommending 
pulling  with  the  finger  in  the  mouth,  he  added,  "  If 
the  operator  is  afraid  of  injuring  or  overstraining  the 
lower  jaw,  let  him  push  his  fingers  farther  up,  and 
press  on  each  side  of  the  nose."  This  is  sometimes 
called  Smellie's  method.  It  is  useless,  for  the  force 
that  can  be  exerted  by  it  is  limited  by  the  friction 
*  "Midwifery,"  N.S.S.  Edn.,  vol.  i.  p.  307. 


52  Difficult  Labour. 

between  your  greased  finger  tips  and  the  slippery  skin 
of  the  foetus,  and  amounts  to  almost  nothing. 

The  advantages  of  jaw  traction  are  that  (1)  you  not 
only  get  a  hold  of  the  head  by  which  to  pull  on  it ;  but 
(2)  you  ensure  the  proper  mechanism,  you  prevent  ex- 
tension of  the  head;  and  (3)  by  combining  it  with  pulling 
on  the  shoulders  you  halve  the  force  required  by  either 
plan  separately.  Strong  pulling  on  the  shoulders 
alone  may  tear  the  cord  or  its  meninges,  or  even 
fracture  the  spine ;  and  if  there  be  resistance  it  may 
extend  the  head.  By  pulling  at  the  same  time  on  the 
shoulders  and  the  jaw,  we  can  get  the  same  amount  of 
force  to  move  the  head  onwards,  with  only  half  the 
danger  of  injury  to  the  child ;  and  extension  is 
prevented. 

In  practice,  you  must  often  resort  to  jaw  traction, 
for  this  simple  reason,  that  it  needs  no  instruments. 
If  the  after-coming  head  is  detained,  it  must  be 
delivered  quickly.  There  is  not  time  to  send  for 
instruments.  If  you  have  not  forceps  ready,  you 
must  deliver  in  some  other  way ;  and  jaw  traction 
combined  with  shoulder  traction  is  the  best  way  of 
non-instrumental  delivery. 

Mechanical  effect  of  jaw  traction. — The  main 

utility  of  jaw  traction  is  as  a  means  of  traction.  In 
a  preceding  paragraph  I  have  used  the  words  "pre- 
vent extension,"  instead  of  "  produce  flexion."  If 
with  the  finger  you  pull  down  the  jaw,  the  head 
can  scarcely  get  extended,  and  therefore  by  this  mode 
of  delivery  you  do  prevent  extension.  But  the 
power  you  have  of  producing  flexion  is  very  slight 
indeed,  for  the  pull  is  exerted  through  the  muscles  and 
ligaments  attaching  the  jaw  to  the  base  of  the  skull ; 
and  the  attachment  is  only  a  little  in  front  of  the 
occipito-spinal  joint.  The  force  used  acts  at  much  less 
advantage  in  producing  flexion  than  as  a  simple  down- 
ward pull.  And  the  production  of  flexion  is  quite 
unnecessary  if  only  great  extension  is  avoided,  for  if 
the  chin  descends  into  the  pelvis,  the  pressure  of  the 
pelvic  wall  on  the  occiput  will  flex  the  head.     Pulling 


FORCEPS    TO    THE    AFTER-COMING   HEAD. 


53 


on  the  chin,  combined  with  pulling  on  the  shoulders, 
is  a  better  way  of  traction  than  pulling  on  either  chin 
or  shoulders  alone  (Fig.  32).  It  is  better  still  to  com- 
bine it  with  pressure  from  above,  so  limited  to  the 
front  of  the  head  as  not 
to  interfere  with  the 
moulding  of  the  part  of 
the  head  opposed  to  the 
conjugate. 

It  is  often  recom- 
mended to  help  flexion 
by  pressing  up  the 
occiput  with  one  or  two 
fingers  of  the  hand 
which  is  pulling  on  the 
shoulders.  The  reason 
given  for  considering 
the  effect  of  jaw  traction 
in  producing  flexion  un- 
important, applies  to 
this  recommendation 
also. 

Forceps  to  the 
after  coming  head. — 

This  is  the  best  way  of 
delivering  it  when  help 
is  needed.  I  have  de- 
livered with  forceps 
after  others  and  I  my- 
self had  failed  to  de- 
liver by  jaw  traction  Fig.  32.— Delivery  of  Head  by  combined 
j  £     „  Jaw  and  Shoulder  Traction.    (After 

and  pressure  from  chaiiiy  Honori.) 
above.  Pulling  is  bet- 
ter than  pressure  for  this  reason  :  when  the  after- 
coming  head  is  delivered  by  pulling  on  the  shoulders 
and  jaw,  the  pressure  of  the  contracted  brim  as  the 
head  comes  down  presses  the  parietal  bones  together, 
so  that  they  meet  in  the  sagittal  suture  at  a  slight  angle. 
(See  Fig.  85,  page  206.)  It  thus  makes  the  vertex 
less  flat  and  more  pointed,  and  lessens  the  transverse 


54  Difficult  Labour. 

measurement  of  the  skull.  The  forceps  acts  in  the  same 
way,  for  its  grip  is  applied  to  the  part  of  the  head  which 
is  in  contact  with  the  side  walls  of  the  pelvis ;  it  does 
not  press  on  the  top  of  the  head,  and  therefore  does 
not  prevent  moulding.  Therefore  in  a  breech  case  in 
which  you  apprehend  difficulty  with  the  after-coming 
head,  have  the  forceps  ready  boiled,  in  a  jug  of  boiled 
water.  Peel  the  pulsations  of  the  cord.  If  traction 
does  not  deliver,  and  the  pulsations  are  getting  slower 
or  irregular,  apply  the  forceps  without  delay.  It  is 
not  more  difficult  to  apply  forceps  to  the  after-coming 
than  to  the  fore-coming  head.  If  forceps  traction  fails, 
the  pulsation  of  the  cord  will  soon  stop.  After  the 
cord  has  ceased  to  beat,  inflict  not  on  the  mother 
further  risk  of  damage  to  her  soft  parts,  but  cease 
pulling,  remove  the  forceps,  and  take  up  the  perforator. 

As  a  rule,  if  the  head  is  not  extracted  within  five 
minutes  after  the  liberation  of  the  arms,  the  child 
will  die. 

It  has  been  recommended,  by  the  introduction  of 
two  fingers  into  the  mouth,  to  keep  open,  between  the 
two  fingers,  an  air  channel,  through  which  the  child 
may  breathe,  pending  the  success  of  efforts  at  delivery, 
and  thus  death  from  asphyxia  be  prevented.  In  my 
opinion  this  is  unnecessary,  because  a  child  that  can 
be  delivered  alive  at  all,  can  be  delivered  quickly  with 
the  forceps.  I  agree  with  Spiegelberg,  who  says  that 
the  preservation  of  life  by  this  manoeuvre  will  be 
more  due  to  good  luck  than  to  anything  else. 

Arrest  in  the  pelvic  cavity. — The  head  may  have 
passed  the  brim,  and  come  down  into  the  pelvic  cavity, 
and  pulling  may  be  required  to  deliver  it.  If  the 
natural  mechanism  has  not  been  interfered  with,  the 
occiput  will  be  in  front,  the  face  in  the  hollow  of  the 
sacrum,  the  chin  pressing  on  the  perineum.  When 
the  head  is  in  this  position,  the  proper  mode  of  delivery 
is  by  what  is  called  the  "  Prague  method  "  (Fig.  33). 
Wrap  the  limbs  of  the  child  in  a  napkin.  Grasp  the  legs 
with  your  right  hand-  Put  the  palm  of  your  left  hand 
on  the  front  of  the.  child's  trunk,  and  the  index  and 


The  "Prague"  Method. 


55 


middle  finger  one  over  each  shoulder.  Carry  the  legs 
with  your  right  hand  as  far  up  over  the  mother's 
abdomen  as  you  can,  and  then  by  the  combined  pulling 
of  the  two  hands  pull  the  neck  and  shoulders  for- 
wards. Thus  you  have  a  "  couple  "  of  forces ;  you  pull 
forwards  the  front  of  the  head,  while  the  resistance 


Fig- 


S3.— The  so-called  "Pi  ague  "Method  of  Delivering  the  after-coming 
Head. 


of  the  symphysis  pubis  presses  back  the  occiput.  Thus 
the  head  is  flexed,  and  put  in  the  best  position  for  pass- 
ing the  outlet.  Put  in  another  way :  the  head  is  con- 
verted into  a  lever  of  the  third  order,  the  power 
being  the  pull  applied  through  the  neck  ;  the  fulcrum 
the  symphysis  pubis ;  the  weight  the  resistance  of 
the  soft  parts. 

This  mode  of  pulling  is  only  suitable  when  the  head 


56  Difficult  Labour. 

has  quite  descended  into  the  pelvic  cavity,  and  is 
therefore  ready  to  make  its  movement  of  rotation 
round  the  symphysis  pubis.  You  may  grasp  it  in 
this  manner  if  you  like,  before  it  has  descended  so 
low ;  but  if  so,  you  must  pull  downwards,  but  not 
forwards  until  the  face  is  in  the  hollow  of  the  sacrum. 

If  pulling  by  the  Prague  method  is  not  enough  to 
deliver  the  head,  forceps  may  be  applied  when  it  is  in 
the  cavity  as  well  as  when  it  is  above  the  brim. 

Arrest  of  head  by  the  imperfectly  dilated 
cervix  Uteri. — The  advance  of  the  head  may  be 
hindered  by  the  cervix,  which  although  dilated  enough 
to  let  the  trunk  pass,  is  not  large  enough  to  let  the 
greatest  diameter  of  the  head  pass.  If  the  delivery 
of  the  body  has  been  so  hurried,  by  pulling  too  soon, 
that  the  arms  have  been  kept  up,  we  have  the  head 
and  arms  imprisoned  by  a  cervix  just  big  enough  to  let 
the  body  slip  through.  The  strong  probability  is  that 
either  it  will  be  such  a  long  and  difficult  task  to  get 
down  the  arms  that  the  child  will  be  stillborn,  or  that 
in  forcing  up  the  hand  to  bring  down  the  arms  quickly, 
the  cervix  will  be  extensively  torn.  The  arms  must 
be  liberated  as  gently  as  possible ;  and  the  stretching 
of  the  cervix,  which  cannot  be  avoided  in  bringing 
down  the  arms,  will  probably  make  the  canal  big 
enough  to  let  the  head  pass. 

If  the  arms  are  down  by  the  side  of  the  chest,  and 
the  head  is  retained  by  the  os  uteri  not  being  large 
enough  to  let  its  greatest  diameter  pass,  apply  the 
forceps. 

Delivery  with  face  anterior. — In  the  third  or 

fourth  breech  position  the  occiput  ought  to  turn 
forwards.  This  does  not  always  happen.  In  some 
rare  cases,  from  causes  which  have  not  yet  been  ascer- 
tained, the  face  remains  in  front.  In  that  case  delivery 
may  take  place  in  one  of  two  ways :  (a)  The  head 
may  remain  flexed,  and  thus  pass ;  chin,  mouth,  nose, 
forehead,  successively  passing  down  behind  the  pubes 
(Fig.  34).  This  is  an  unfavourable  mode  of  delivery, 
because  the  curve  of  the  pelvic  canal  causes  the  neci 


After-coming  Head  with  Face  Anterior.    57 

to  be  so  carried  forward  that,  however  much  the  head 
be  flexed,  the  sub-occipito-frontal  diameter  cannot  be 
brought  into  the  brim.  The  diameter  that  has  to  pass 
the  brim  is  the  occipito-frontal,  which  averages  four 
inches  and  a  half,  instead  of  the  four  inches  of  the 
sub-occipito-frontal.  (b)  The  chin  may  meet  with 
resistance  from  the  symphysis  pubis,  and  thus  the 


Fig.  84.— Delivery  of  after-coming  Head  with  Face  anterior  :  head  flexed. 


head  get  extended.  The  chin  rests  above  the  sym- 
physis, the  front  of  the  neck  hugs  the  back  of  the 
symphysis,  the  head  then  rotates  round  the  symphysis, 
the  occiput  being  first  born  (Fig.  35).  In  this  mode 
of  delivery  the  cervioo-vertical  measurement,  which 
is  four  inches  and  a  half,  is  opposed  to  the  pelvic 
antero-posterior  diameter. 

These  deviations  from  the  normal  mechanism  are 
usually,  and   probably  always,  produced  by  untimely 


58 


Difficult  Labour. 


pulling.  They  are  excessively  rare,  if  they  occur  at 
all,  in  cases  in  which  delivery  is  left  to  nature,  or 
interference  strictly  limited  to  assisting  nature. 

Madame  La  Chapelle  (whose  vast  experience  makes 
her  advice  weighty)  recommended  that  if  the  face  be 
in  front,  the  hand  should  be  passed  up  in  the  hollow  of 
the  sacrum,  behind  the  head,  and  then  moved  round 


Fig.  35.— Delivery  of  after-coming  Head  with  Face  anterior :  head  extended. 


the  side  of  the  head  to  reach  the  mouth  In  doing 
this  the  head  will  be  turned  so  that  the  face  looks  to 
the  side  of  the  pelvis,  which  is  the  way  in  which  it  can 
best  pass  the  brim.  If  this  manoeuvre  fail,  forceps 
should  be  used.  If  forceps  fail,  perforation  is  the 
only  resource. 

Injuries  to  the  child  in  breech  deliveries. — 

The  pulling  on  the  child,  which  is  necessary  in  difficult 
breech  deliveries,  often  does  damage. 


Ixjuries   to   Child   in  Breech  Labours.  59 

Pulling  on  the  breech  may  injure.  Even  with  the 
fingers  ecchymosis  may  result.  The  fillet  may  bruise 
or  even  cut  the  soft  parts  :  hence  the  desirability  of 
using  something  thick  and  soft.  The  blunt  hook 
may  with  its  point  injure  the  genitals  or  the  femoral 
vessels,  if  so  applied  that  its  point  presses  on  these 
parts.  It  may  dislocate  the  femur,  or  separate  the 
shaft  from  the  upper  epiphysis,  although  both  these 
injuries  are  rare. 

Bringing  down  a  foot  and  pulling  on  it  may 
separate  the  lower  epiphysis  of  the  femur  from  the 
shaft.  Therefore,  in  pulling  on  the  limb  brought  down, 
hold  it  as  high  as  possible.  In  case  of  injury  to  the 
thigh  it  is  difficult,  if  not  impossible,  in  consequence 
of  the  movements  of  the  child  and  the  necessity  for 
keeping  it  clean,  to  keep  the  injured  bone  at  rest  by 
any  of  the  methods  used  for  older  subjects.  Crede 
recommended  fastening  the  thigh  up  to  the  abdomen 
by  means  of  a  soft  napkin  passed  round  the  popliteal 
space. 

In  bringing  down  tlie  arms,  fracture  of  the  humerus 
is  likely  to  happen  if  the  humerus  is  pulled  on  near 
the  shoulder,  instead  of  being  pushed  down  by  the 
fingers  applied  at  the  elbow.  In  rotation  of  the  child 
to  liberate  the  arm  displaced  behind  the  neck, 
separation  of  the  upper  epiphysis  may  happen.  The 
treatment  of  these  injuries  is  to  bind  the  arm  to  the 
side  of  the  chest  with  splints  if  there  be  deformity. 
Fracture  of  the  clavicle  may  happen  if  the  hand  is 
forced  up  violently  between  the  side  of  the  child  and 
the  pelvis.  It  may  also  happen  in  pulling  down  the 
body  of  the  child  with  the  fingers  on  the  shoulders  to 
bring  the  arms  within  reach.  This  is  one  of  the 
commonest  injuries  sustained  in  breech  deliveries.  In- 
order  to  avoid  it,  be  gentle  in  manipulation. 

By  pulling  on  the  trunk  of  the  child,  the  liver  or 
the  suprarenal  capsules  may  be  crushed,  the  lungs 
may  be  injured,  and  the  child  in  consequence  die 
from  pneumonia  within  a  few  clays  of  birth.  To 
Mvoid  this,  seize  the  child  by  the  pelvis,  the  bones  of 


60  Difficult  Labour. 

which  will  protect  the  soft  parts  they  enclose  from 
injury.  If  this  is  done  a  tight  grasp  will  only  cause 
some  bruises  over  the  hips.  There  may  be  hemorrhages 
into  the  muscles  of  the  spine.  When  great  force  has 
been  used  the  spinal  cord  has  been  torn  across,  and 
the  vertebral  column  has  been  injured.  Such  injury 
may  be  associated  with  great  haemorrhage  into  the 
cellular  tissue  behind  the  peritoneum  and  pleura. 
When  the  spine  is  injured,  the  body  of  a  vertebra  is 
generally  torn  from  the  epiphysis  (which  remains 
attached  to  the  intervertebral  cartilage),  and  the 
anterior  vertebral  ligament  torn  through.  The 
testicle  may  be  injured,  either  by  the  pressure  of  the 
genital  canal,  or  by  the  attendant's  fingers  or  instru- 
ments. Hence  be  careful  in  examining  to  manipulate 
the  scrotum  as  little  as  possible.  It  is  difficult  to 
understand  the  great  liability  of  the  testis  to  injury ; 
but  Spencer*  found  haemorrhage  into  the  testicle 
present  in  about  one-third  of  children  born  dead 
after  delivery  with  the  breech  in  advance.  He  has 
pointed  out  that  this  explains  the  occasional  occur- 
rence of  orchitis  in  infants,  and  may  be  the  explanation 
of  some  cases  of  male  sterility.  He  mentions  a  case 
in  which  a  hematocele,  produced  during  delivery, 
was  mistaken  for  a  melanotic  sarcoma,  and  the 
testicle  in  consequence  removed.  He  suggests  that 
similar  injury  to  the  uterus  may  account  for  the 
hemorrhage  from  the  uterus  occasionally  seen  in 
infants :  but  the  uterus  is  so  well  protected  that  I 
can  hardly  understand  this. 

The  most  serious  injuries  are  those  which  may  be 
inflicted  in  'pulling  the  head  through.  These  are 
sometimes  almost  inevitable,  for  the  head  must  be 
delivered  quickly,  and  to  deliver  quickly  in  a  difficult 
case,  you  must  pull  hard.  The  fingers  applied  over 
the  clavicles  may  fracture  them,  or  may  so  injure  the 
brachial  plexus  as  to  cause  paralysis,  lasting  for  days 
or  weeks  after  birth.  This  paralysis,  fortunately, 
always  gets  well.  The  cervical  spine  may  be  torn 
through,  and  the  spinal  cord.  This  is  especially  likely 
*  Brit.  Med.  Journal,  May  18th.  1901. 


Injuries  to  Child  in  Breech  Labours.    61 

to  happen  in  the  Prague  method  of  delivering  the 
head,  because  in  this  the  whole  force  is  exerted  through 
the  neck.  The  neck  is  seldom  torn  quite  through,  be- 
cause the  soft  parts  hold  together  longer  than  the 
spinal  column,  but  it  is  possible,  especially  in  prema- 
ture and  dead  children,  by  pulling  to  detach  the  body 
from  the  head.  Haemorrhages  into  the  muscles  and 
cellular  tissue  of  the  neck  may  occur. 

One  result  of  this  haemorrhage  is  well  known, 
viz.  hcematoma  of  the  sterno-mastoid  muscle.  This 
forms  a  tumour  usually  on  one  side  only,  and  usually 
situated  on  the  anterior  half  of  the  muscle.  It  forms 
a  swelling  as  big  as  a  pigeon's  egg  or  larger.  It 
generally  disappears  within  six  months  after  birth. 
It  may  last  longer.  In  about  half  it  leads  to 
torticollis.  It  is  much  commoner  on  the  right  side 
than  on  the  left,  because  in  the  most  frequent  breech 
positions  the  head  comes  down  with  the  face  looking 
to  the  right  side,  and  therefore  the  right  sterno- 
mastoid  is  the  more  pulled  upon. 

In  helping  delivery  by  the  finger  in  the  mouth, 
the  mucous  membrane  may  be  torn,  the  two  halves  of 
the  jaw  may  be  separated  at  the  symphysis,  the  jaw 
may  be  dislocated,  or  the  condylar  epiphysis  may  be 
detached.  On  the  average,  a  force  of  above  fifty 
pounds  is  required  to  damage  the  jaw.* 

Lastly,  the  skull  and  brain  may  be  injured.  The 
basilar  portion  of  the  occipital  bone  may  be  separated 
from  the  squamous.  The  parietal  bones  may  be 
fractured.      Meningeal  haemorrhage  may  take  place. 

*  Duncan,  Obst.  Trans.,  1878. 


62 


CHAPTER    VI. 

TRANSVERSE    PRESENTATIONS. 

Transverse  presentations  include  all  cases  in  which 
any  part  other  than  the  head  or  breech  presents. 

The  causes  of  transverse  presentations. 
Premature  or  decomposing  children. — The  great 
cause  of  the  frequency  of  head  presentations  is  the 
continually  acting  force  of  gravity.  It  is  found  by 
experiment  that  a  child  at  full  term,  so  recently  dead 
that  decomposition  has  not  commenced,  floats  in  fluid 
of  about  its  own  specific  gravity  in  exactly  the  posi- 
tion which  it  occupies  in  utero.  In  premature  child- 
ren the  centre  of  gravity  is  not  the  same  as  in  full- 
term  children,  and  its  position  is  also  altered  by 
decomposition.  Hence,  with  premature  and  dead 
children,  gravity  does  not  help  to  make  the  head 
present.  Transverse  presentations  occur  about  once 
in  200  labours  at  full  term,  but  once  in  about  eight 
labours  with  premature  or  decomposing  children. 

The  action  of  the  uterus,  in  driving  the  head  into 
the  brim,  requires  for  its  effect  some  degree  of  stiffness 
of  the  foetal  trunk,  or  else  the  pressure  of  the  uterus 
on  the  breech  is  not  transmitted  to  the  head.  In 
decomposing  children,  this  stiffness  is  lost.  This 
abnormal  flexibility  of  the  child  helps  other  causes  that 
have  been  named,  to  bring  about  transverse  presenta- 
tions of  decomposing  children. 

Non-engagement  of  head  in  pelvis. — Gravity 

makes  the  head  sink  towards  the  brim.  If  the  pelvis 
is  large  enough,  the  head  becomes  engaged  in  the  brim, 
and  is  held  there  by  the  contraction  of  the  uterus  round 
it.  In  the  later  months  of  pregnancy  the  child  grows  so 
much  faster  than  the  liquor  amnii  increases,  that  after 
the  seventh  month  it  can  no  longer  be  said  to  float  in 
the  liquor  amnii,  for  it  can  move  very  little  indeed 


Causes  of  Transverse  Presentations.     63 

without  coming  into  contact  with  the  uterus,  and  the 
uterus,  therefore,  holds  it  in  the  brim.  The  more 
nearly  the  axis  of  the  uterus  is  continuous  with  that 
of  the  pelvic  brim,  the  more  effective  will  its  con- 
traction be,  in  driving  the  head  into  the  pelvic  brim, 
and  keeping  it  there.  Conditions  which  interfere  with 
this  natural  order  of  things  will  favour  transverse  pre- 
sentations. 

Defective  Uterine  action. — The  uterus,  by  keep- 
ing the  head  pressed  into  the  pelvis,  has  much  to  do 
with  securing  a  normal  presentation.  If  it  does  not  do 
this,  transverse  presentations  are  apt  to  occur.  The 
best  example  of  the  effect  of  weakness  of  the  uterus  in 
allowing  representations,  is  in  the  case  of  the  second 
child  of  twins ;  half  of  which  present  transversely. 
If  the  uterus  is  sunk  forward,  as  in  pendulous  belly, 
or  deviated  laterally,  it  will  not  act  so  well  in  keeping 
the  head  pressed  into  the  brim.  Hence,  transverse 
presentations  are  commonerin  niultipane  thanin  primi- 
parse,  because  in  the  former  the  abdominal  walls  (from 
previous  stretching)  are  looser  and  do  not  support  the 
uterus  so  well  as  in  the  latter.  Pendulous  belly  and 
lateral  obliquity  of  tlie  uterus  frequently  go  with 
contracted  pelvis,  so  that  here  we  have  another 
instance  of  the  coincidence  of  more  than  one  cause 
leading  to  transverse  presentations. 

Obliquity  Of  the  Uterus. — If  the  uterus  is  oblique 
the  long  axis  of  the  child  is  oblique,  too.  This  obliquity 
tends  to  move  the  head  towards  the  iliac  fossa  of  the 
side  opposite  to  that  to  which  the  fundus  uteri  leans. 
In  a  well-shaped  pelvis  the  obliquity  must  be  extreme 
to  bring  the  head  into  the  iliac  fossa.  But  in  a  con- 
tracted pelvis,  a  slight  degree  of  uterine  obliquity  may 
determine  whether  the  head  lies  over  the  brim  or  in  an 
iliac  fossa  (Fig.  36).  If  the  head  be  so  far  displaced 
to  the  side  that  the  ilium  hinders  its  descent,  the 
effect  of  the  forces  of  labour  will  usually  be  to  drive 
down  the  shoulders,  and  drive  the  head  farther 
towards  the  side. 

This  effect  of  uterine  obliquity  is  shown  to  be  a 


64 


Difficult  Labour. 


reality  by  the  fact  that  presentations  of  the  right 
shoulder  (the  back  being  anterior)  are  more  common 
than  presentations  of  the  left.  As  right  uterine 
obliquity  is  commoner  than  left,  this  is  exactly  what 


A- 


Fig.  36. — Showing  the  earliest  Stage  In  the  Production  of  transverse 
Presentations  by  uterine  Obliquity  :  that  which  is  probably  often 
spontaneously  rectified.     (After  B.  Barnes.) 

a  b,  Plane  of  brim ;  o  n,  normal  axis  of  uterus ;  v.  p,  axis  of  child  and  uterus ; 
o  h,  line  of  action  of  abdominal  muscles  and  diaphragm. 

we  should  expect.  The  back  is  usually  anterior  in 
shoulder  presentations,  for  the  same  reason  that  it  is 
in  head  presentations. 

Hydramnios. — If  there  is  excess  of  liquor  amnii, 
so  that  the  child  floats  about  freely  in  the  womb  up  to 


Causes  of  Transverse  Presentations.     65 

the  end  of  pregnancy,  instead  of  being  pressed  into  the 
brim  and  held  there  by  the  action  of  the  uterus,  then  it 
is  possible  that  at  the  moment  when  the  membranes 
rupture,  the  head  may  not  be  exactly  over  the  brim, 
and  the  child  will  fall  across  the  brim  in  a  transverse 
or  oblique  position.  In  dropsy  of  the  amnion 
labour  often  comes  on  prematurely,  so  that  in  these 
cases  we  often  have  two  causes  acting  together  to 
prevent  a  natural  presentation.  Therefore,  cross-births 
are  common  with  hydramnios. 

Contracted  pelvis. — If  the  pelvic  brim  is  con- 
tracted, the  head  may  not  be  able  to  enter  it.  Then 
it  may  get  in  one  iliac  fossa,  and  the  shoulder  will 
present.  Transverse  presentations  have  been  found 
to  occur  twice  as  often  in  labours  with  contracted 
pelvis,  as  in  those  with  normal  pelvis. 

Tumours,  either  of  the  pelvic  bones  or  of  the  soft 
parts,  which  at  all  obstruct  the  entry  of  the  head  into 
the  brim,  will  act  just  like  contracted  pelvis  in  causing 
transverse  presentations. 

Placenta  praevia  renders  the  entrance  of  the  head 
rather  less  easy,  and  in  this  complication  labour  is 
often  premature,  so  that  here  again  we  have  a  com- 
bination of  causes. 

Modes  Of  natural  delivery. — Before  consider- 
ing the  treatment  of  shoulder  presentations,  let  us  see 
how  nature  can  deal  with  this  difficulty.  There  are 
four  ways  in  which  delivery  may  take  place  naturally 
in  transverse  presentations. 

Spontaneous  rectification. — The  first  is  spon- 
taneous rectification.  The  foetus  rarely  lies  trans- 
versely. It  usually  lies  obliquely,  with  the  head  in 
one  iliac  fossa,  and  the  shoulder  lying  over  the  pelvic 
brim.  The  head  bulges  out  the  uterine  wall  at  the 
side  to  which  it  is  directed.  As  the  uterus  contracts, 
it  tends  to  assume  its  own  proper  shape ;  and  this 
tendency  is  resisted  by  the  head  bulging  in  the  iliac 
fossa.  If  the  child  is  freely  movable,  the  pressure  of 
the  uterus  against  the  head  may  press  the  head 
towards  the  brim  so  effectively  that  the  head  becomes 

f— 36 


66  Difficult  Labour. 

engaged  in  the  brim,  and  becomes  the  presenting  part. 
It  is  known  that  the  position  of  the  child  is  fre- 
quently changed  during  pregnancy,  and  from  that  fact 
it  may  be  inferred  that  oblique  positions  are  often 
rectified  during  pregnancy.  Rectification  may  take 
place  during  the  first,  or  at  the  beginning  of  the  second 
stage  of  labour.  It  is  necessary  for  its  occurrence 
that  (a)  the  child  should  be  movable,  and  also  (b)  that 
there  should  not  be  too  much  liquor  amnii :  for 
{a)  if  the  presenting  part  is  so  driven  down  into  the 
brim  that  it  cannot  move  laterally,  then  spontaneous 
rectification  is  impossible ;  and  (b)  if  there  is  a  great 
deal  of  amniotic  fluid,  the  pressure  of  the  fluid,  press- 
ing equally  in  all  directions,  tends,  during  uterine 
contractions,  to  make  the  uterine  cavity  as  nearly 
spherical  as  its  structure  and  surroundings  will  allow  ; 
and  also  protects  the  child  from  the  pressure  of  the 
uterine  wall. 

We  do  not  know  why  it  is  that  in  one  case  uterine 
action  drives  down  the  shoulder,  and  in  another  presses 
the  head  into  the  brim.  In  a  case  of  oblique  presenta- 
tion early  in  labour  you  therefore  have  no  means  of 
knowing  whether  spontaneous  rectification  is  likely 
to  happen  or  not,  but  the  probability  is  against  it. 
Therefore,  do  not  wait  for  its  occurrence,  but  imitate 
nature,  and  rectify  the  position  by  pressure  with 
the  hands  on  the  abdomen. 

Spontaneous  version  (Denman). — The  second 
mode  by  which  delivery  is  sometimes  naturally  ended 
in  transverse  presentations  is  called  spontaneous  version. 
It  was  first  described  by  Denman,  under  the  title  of 
"  spontaneous  evolution;  "  but  this  name  is  now  given 
to  a  different  process,  which  was  first  described  by 
Douglas.  As  these  two  processes  have  been  in  some 
text-books  confused  together,  I  keep  as  closely  as  is 
convenient  to  the  language  of  the  original  descriptions. 

Denman's*  description  of  spontaneous  version 
(  "  evolution  "  as  he  called  it)  is  the  following  :  "  The 
body  is  brought  into  such  a  compacted  state  as  to 
*  "Introduction  to  the  Practice  of  Midwifery,"  7th  edn.,  p.  355 


Spontaneous   Version. 


67 


receive  the  full  force  of  every  returning  pain.  The 
body  in  its  doubled  state,  being  too  large  to  pass 
through  the  pelvis,  and  the  uterus  pressing  upon  its 
inferior  extremities,  which  are  the  only  parts  capable 


Fig.  37. — Showing  what  takes  Place  in  spontaneous  Version :  descent  of 
breech,  ascent  of  shoulder.    {After  R.  Barnes.) 

A.B,  Plane  of  brim  ;  cd, normal  axis  of  child  and  uterus;  b  f,  axis  of  child  lying 
obliquely ;  q  u,  direction  of  pressure  exerted  by  diaphragm  and  abdominal 

muscles. 

of  being  moved,  they  are  forced  gradually  lower, 
making  room  as  they  are  pressed  down  for  the  reception 
of  some  other  part  into  the  cavity  of  the  uterus  which 
they  have  evacuated,  till  the  body,  turning  as  it  were 
upon  its  own  axis,  the  breech  of  the  child  is  expelled, 


68  Difficult  Labour. 

as  in  an  original  presentation  of  that  part  (Fig.  37). 
Nor  has  there  been  anything  uncommon  in  the  size  or 
form  of  the  pelvis  of  these  women  to  whom  this  case 
has  happened,  nor  have  the  children  been  small  or  suf- 
fered by  putrefaction.  I  believe,  on  the  contrary,  that  a 
child  of  the  common  size,  hiving,  or  but  lately  dead,  in 
such  a  state  as  to  possess  such  a  state  of  resilition,  is 
the  best  calculated  for  expulsion  in  this  manner. 
Premature  or  very  small  children  •  have  often  been 
expelled  in  a  doubled  state,  whatever  might  be  the 
original  presentation,  when  the  pelvis  was  well  formed, 
or  rather  more  capacious  than  ordinary  :  but  this  is  a 
different  case  to  that  we  are  now  describing." 

Spontaneous  version  as  a  rule  takes  place  later  in 
labour  than  spontaneous  rectification.  It  always  takes 
place  in  the  uterus :  never  in  the  pelvis.  It  is  supposed 
to  be  due  to  irregular  uterine  contraction,  so  that  while 
one  part  of  the  uterus  is  contracting  and  pressing  down 
the  breech,  the  part  over  the  head  is  relaxed  so  that 
the  head  can  move  up.  But  this  is  only  theoiy.  No 
observations  showing  how  spontaneous  version  ia 
effected  have  been  made.  We  know  nothing  as  to  the 
conditions  on  which  it  depends ;  we  cannot  predict  its 
occurrence.  Therefore  act  as  if  there  were  no  such 
thing  as  spontaneous  version. 

Spontaneous  evolution  {Douglas). — This  was 
first  described  by  Dr.  John  C  Douglas,  of  Dublin. 
In  the  following  description  I  keep  very  close  to  Dr. 
Douglas's  words.  In  the  second  stage  of  labour  the 
shoulder  is  forced  very  low  into  the  pelvis.  The 
shoulder  and  thorax  are  at  each  successive  pain  forced 
still  lower,  until  the  ribs  press  on  the  perineum,  and 
cause  it  to  assume  the  same  form  as  it  would  by  the 
pressure  of  the  forehead  in  a  natural  labour.  At  this 
period  not  only  the  entire  arm,  but  the  shoulder,  can 
be  perceived  externally,  with  the  collar-bone  lying 
under  the  arch  of  the  pubes  (Fig.  38).  By  further 
uterine  contractions  the  ribs  are  forced  more  forward, 
appearing  at  the  orifice  of  the  vulva,  as  the  vertex 
would  in  a  natural  labour,  the  clavicle  having  been  by 


Spontaneous  Evolution.  69 

degrees  forced  round  on  the  anterior  part  of  the  pubes. 
The  entire  foetus,  immediately  prior  to  its  expulsion, 
somewhat  resembles  the  larger  segment  of  a  circle ; 
the  head  rests  on  the  pubes  internally,  the  collar-bone 
presses  against  the  pubes  externally.  The  arm  and 
shoulder  are  entirely  protruded,  with  one  side  of  the 
thorax  not  only  appearing  at  the  vulval  orifice,  but 
partly  beyond  it ;  the  lower  part  of  the  same  side  of 
the  trunk  presses  on  the  pei'ineum,  with  the  breech 


Fig.  38.— Spontaneous  Evolution  in  Progress  :  arm  outside  vulva,  side  of 
neck  behind  pubes,  side  of  chest  pressing  on  perineum. 

either  in  the  hollow  of  the  sacrum,  or  at  the  brim  of 
the  pelvis,  ready  to  descend  into  it.  By  a  few  further 
uterine  efforts,  the  remainder  of  the  trunk,  with  the 
lower  extremities,  is  expelled  (Fig.  39).  Delivery  is 
finished  as  in  a  labour  in  Which  the  breech  had 
presented  (Fig.  40). 

This  mode  of  delivery  takes  place  when  the  foetus 
has  descended  into  the  pelvic  cavity.  It  requires 
very  powerful  uterine  action  to  accomplish  it.  If 
only  the    uterus  is  strong   enough,  a  full-time  child 


7o 


Difficult  Labour. 


may  be  delivered  through  a  pelvis  of  average  size  in 
this  way,  and  may  survive.  Delivery  in  this  way,  if 
it  .is  going  to  take  place  at  all,  will  do  so  quickly. 
In  the  cases  recorded  by  Dr.  Douglas,  the  labour  was 
in  each  case  over  in  less  than  six  hours.  But  it  is 
very  seldom  that  the  uterus  is  strong  enough  to  drive 


F!g.  39.— Further  Stage  of  spontaneous  Evolution  :  side  of  nock  still  Axed 
behind  pubes,  chest  and  pelvis  delivered,  legs  about  to  follow. 

out  the  child  in  this  way,  and  therefore  you  must  not 
expect  or  wait  for  this  to  happen. 

Spontaneous  expulsion.— The  fourth  way   is 

called  "  spontaneous  expulsion "  or  "partus  corpore 
conduplicato."  In  it  the  child  is  driven  through  the 
pelvis  doubled  up,  so  that  its  chest  and  belly  come  out 
first,  and  then  its  head  and  legs  (Fig.  41).  This  only 
happens  with  dead  children,  whose  bodies  are  by  de- 
composition rendered  softer  than  natural,  so  that  they 
can  double  up  more  easily.  Dead  children  are  often 
premature.  A  premature,  dead,  and  decomposed  child 
can  easily  be  delivered  in  this  way. 

The  frequency  of  delivery  in  shoulder  presentations 
of  a  full-time  child,  by  one  of  these  natural  ways,  has 


Neglected  Transverse  Presentations.    71 

been  variously  estimated  at  from  1  in  10  to  1  in  40. 
The  frequency  with  which  it  is  observed  must  obviously 
vary  according  to  the  length  of  time  during  which  the 
labour  is  allowed  to  go  on  before  the  unfavourable 
position  is  corrected.     Taking  the  most  liberal  estimate, 


H& 


Fig.  40.— Termination  of  spontaneous  Expulsion  :  delivery  of  tnink  and 
lower  extremities  complete,  head  and  posterior  arm  about  to  follow. 


it  will  be  clear  that  great  risk  will  be  run  by  waiting 
for  spontaneous  version  or  evolution. 

Results  if  not  corrected. — If  a  transverse  pre- 
sentation is  not  rectified,  and  the  membranes  burst, 
the  liquor  amhii  flows  away  more  quickly  and  com- 
pletely than  in  head  presentations,  for  the  shoulder 
does  not  come  down  into  and  plug  the  os  as  the  head 
does.  When  the  liquor  amnii  has  run  off,  the  uterus 
closely  embraces  the  child,  and  becomes  as  it  were 
moulded  to  the  shape  of  the  child.   At  first,  the  uterine 


72 


Difficult  Labour. 


wall  is  everywhere  of  nearly  the  same  thickness ;  there 
is  thinning  of  the  cervix,  proportionate  to  the  degree 
of  dilatation  of  the  os,  but  no  thinning  of  the  lower 
segment   of   the   uterus ;    and   the   uterus,   although 


Fig.    41. 


-Spontaneous  Expulsion:   child   doubled   up,    legs   and   head 
expelled  together. 


clinging  close  to  the  child,  yet  alternately  contracts 
and  relaxes,  and  while  it  is  relaxed,  the  child  can  be 
moved  within  it  While  this  is  the  case  the  hand  can 
be  introduced,  if  the  os  uteri  is  large  enough,  and  the 
child   turned,   without  danger.     The   length   of    time 


Neglected  Transverse  Presentations.    73 

that  this  condition  lasts  depends  upon  the  frequency 
and  strength  of  the  pains.  It  generally  persists  until 
the  os  uteri  is  fully  dilated,  and  for  a  little  while 
afterwards. 

Tonic  contraction  and  rupture  of  uterus. — 

If,  after  full  dilatation  of  the  os,  the  position  of  the 
child  is  not  corrected,  and  it  cannot  be  driven  out  by 
spontaneous  evolution  or  expulsion,  further  changes 
take  place.  The  upper  or  active  part  of  the  uterus 
goes  on  contracting  with  increased  violence  and  fre- 
quency. It  pulls  up  and  stretches  the  passive  part  of 
the  uterus — i.e.  the  lower  segment  of  the  body  and 
the  cervix ;  and  by  pulling  up  the  cervix  it  stretches 
the  vagina.  The  greater  part  of  the  child  is  expelled 
from  the  uterine  cavity  into  that  formed  by  the 
stretched  cervix  and  vagina.  The  case  terminates,  if 
neither  spontaneous  evolution  nor  expulsion  occurs, 
nor  help  is  given,  in  one  of  two  ways.  The  pains 
succeed  one  another  so  fast  that  there  comes  to  be  no 
interval  between  them ;  the  uterus  passes  into  a  state 
of  tonic  contraction,  and  this  condition  may  last 
until  the  mother  dies  of  exhaustion.  The  other 
termination,  and  the  rarer  one,  is  rupture  of  the 
thinned  and  stretched  part  of  the  genital  canal. 
In  shoulder  presentations  the  cervix  is  not  nipped 
between  the  pi'esenting  part  and  the  pelvic  brim 
(as  it  often  is  when  the  head  presents  and  the 
pelvis  is  contracted),  and  therefore  generally  the 
cervix  is  drawn  up,  and  the  vagina  is  the  part  that 
gives  way.  How  rare  this  is  may  be  judged  of  by  the 
fact  that  while  transverse  presentations  occur  about 
once  in  200  labours,  rupture  of  the  utei-us  or  vagina 
only  occurs  about  once  in  3,000  labours,  so  that  if  all 
ruptures  were  due  to  transverse  presentation  this 
would  only  give  about  1  in  15  as  so  ending.  But  only 
about  1  ruptured  uterus  or  vagina  in  4  is  due  to 
transverse  presentation,  so  that  this  gives  about  1  in 
60  as  the  proportion  of  transverse  presentations  in 
which  the  genital  canal  is  ruptured.  But  this  small 
proportion  would  no  doubt  be  larger  were  it  not  that 


74  Difficult  Labour. 

in  most  cases  the  danger  is  averted  by  timely  treatment. 
Although  treatment  in  the  vast  majority  of  cases  saves 
the  patient  from  rupture  of  the  uterus  or  vagina,  yet 
there  are  a  few  cases  in  which  such  rupture  is  produced 
by  injudicious  attempts  at  turning.  If  the  hand  is 
forced  into  a  uterus  the  lower  segment  of  which  is 
stretched  and  thinned  to  the  utmost,  there  will  be 
great  danger  that  the  uterus  will  be  ruptured.  In 
transverse  presentation  most  cases  of  rupture  of  the 
uterus  arise  in  this  way,  the  ruptures  that  take  place 
without  interference  being  usually  of  the  vagina. 

Treatment. — The  successful  treatment  of  trans- 
verse presentations  depends  very  largely  upon  early 
diagnosis.  The  position  ought  to  be  recognised  in  the 
beginning  of  labour,  by  external  palpation. 

Consider  now  the  treatment  in  the  different 
circumstances  in  which  you  may  be  called  upon  to 
manage  a  case  of  transverse  presentation. 

First :  The  membranes  unruptured,  and  the  os 
not  larger  than  a  crown  piece.  Rectify  the  position 
of  the  child  by  external  manipulation.  In  other 
words,  perform  external  cephalic  version.  No  harm 
can  be  done  by  trying  to  do  this.  The  only  ill 
result  that  can  happen  is  that  the  attempt  may  fail. 
This  treatment  should  be  preferred,  because  it  is  very 
desirable  that  the  os  should  be  dilated  by  the  bag  of 
membranes.  The  risk  of  rupturing  the  membranes 
that  must  always  go  with  manipulation  of  the  child 
through  them,  is  a  reason  for  postponing  version 
Further,  until  the  os  is  as  big  as  a  crown  piece,  bipolar 
version  and  the  bringing  down  of  a  leg  cannot  easily 
be  done.  An  os  uteri  the  size  of  half-a-crown  will  just 
admit  two  fingers  :  it  must  be  as  big  as  a  crown  to 
admit  two  of  the  operator's  fingers  and  the  child's  foot. 
For  these  reasons  do  not  interfere  at  this  stage  of  the 
labour,  except  to  rectify  the  position  of  the  child  by 
external  manipulation. 

Second :  The  os  is  larger  than  a  crown  piece,  but 
not  fully  dilated  ;  and  the  membranes  unruptured.  The 
welfare  of  the  mother  and  that  of  the  child  are  here 


Trea  tment  of  Tea  nsveese  Present  a  tions.   7  5 

somewhat  opposed.  Freedom  from  subsequent  com- 
plications and  quick  delivery,  which  means  preservation 
of  the  mother's  strength,  are  best  secured  by  performing 
bipolar  version  and  bringing  down  a  foot  as  soon  as 
the  os  is  the  size  of  a  crown  piece.  But  if  this  is  done, 
as  the  body  of  the  child  has  to  dilate  the  os  uteri,  it  is 
very  likely  (from  causes  explained  in  the  chapter  on 
breech  presentations)  that  the  child  will  be  stillborn. 

If  on  the  other  hand  we  wait,  the  dilatation  of  the 
os,  if  the  membranes  remain  entire,  will  go  on  in  a 
natural  manner,  and  when  the  os  is  fully  dilated,  the 
child  can  be  turned  and  quickly  delivered ;  and  if  the 
labour  runs  this  course,. the  danger  to  the  child  (if 
everything  but  the  presentation  is  normal)  is  little,  if 
at  all,  more  than  in  a  normal  labour. 

But  the  labour  does  not  always  go  on  thus.  Often, 
indeed  usually,  the  membranes  rupture  before  full 
dilatation  of  the  os,  because  the  presenting  part  does 
not  fill  the  os  uteri,  and  therefore  does  not  dam  off 
the  bulk  of  the  liquor  amnii  from  the  portion  of  the 
bag  of  membranes  which  is  dilating  the  os.  This  portion 
is  therefore  exposed  to  the  full  intra-uterine  pressure, 
it  bulges  down  like  the  finger  of  a  glove,  and  often 
gives  way  early.  The  liquor  amnii  gradually  drains 
away,  and  the  uterus  more  and  more  closely  hugs  the 
body  of  the  child.  The  more  closely  it  adapts  itself 
to  the  child,  the  more  difficult  and  dangerous  turning 
becomes.  By  postponing  version  we  give  the  child 
the  chance  that  the  membranes  may  persist  till  full 
dilatation  and  the  child  then  be  delivered  living  ;  but 
we  also  expose  the  mother  to  the  risk  that  the  favour- 
able time  for  turning  may  be  lost,  and  the  operation 
be  postponed  until  it  becomes  dangerous. 

If  you  are  able  to  remain  in  close  attendance 
upon  the  patient,  so  that  you  may  at  once  know  when 
the  membranes  rupture,  and  then  turn  or  artificially 
dilate  without  delay,  the  best  practice  is  to  leave 
the  bag  of  membranes  to  dilate  the  os  as  long  as  pos- 
sible. If,  on  the  other  hand,  as  may  happen  in 
country  practice,  the  needs  of  other  patients  make  it 


76  Difficult  Labour. 

impossible  for  you  to  remain  for  hours  near  the  bed- 
side of  one,  the  best  practice  will  be  to  bring  down  a 
leg  as  soon  as  the  os  is  the  size  of  a  crown  piece. 

Third  :  The  os  uteri  is  fully  dilated,  and  the  bag 
of  membranes  entire.  This  is  not  often  the  case,  but 
may  happen.  Perform  internal  podalic  version  and 
deliver. 

Fourth :  The  membranes  are  ruptured.  The  os 
uteri  is  not  large  enough  for  delivery.  Dilate  the 
cervix  with  Champetier  de  Bibes'  dilating  bag,  and 
when  it  is  fully  dilated,  deliver  by  internal  version. 

Fifth  :  The  os  is  fully  dilated  and  the  membranes 
ruptured.  The  uterus  is  moulded  to  the  shape  of  the 
child,  but  regular  pains  are  present,  and  between  the 
pains  the  uterus  softens  and  the  child  is  movable. 
Listen  to  the  foetal  heart,  and  if  the  child  is  alive  bring 
down  a  foot  by  internal  version  and  deliver. 

Sixth  :  The  uterus  is  in  a  state  of  tonic  contraction. 
The  patient  is  in  persistent  pain ;  her  pulse  is  quicker 
than  it  should  be ;  the  uterus  felt  through  the  abdomen 
is  continuously  hard  and  does  not  relax  :  the  child  is 
driven  down  into  the  pelvis  and  you  cannot  push  it  up 
without  great  force.  Listen  for  the  foetal  heart.  If 
you  cannot  hear  it,  and  cannot  perceive  foetal  move- 
ments, the  child  is  probably  dead.  If  the  room  is  so 
noisy  that  you  distrust  your  auscultation,  pass  up  two 
fingers  along  the  abdomen  of  the  child  and  try  and 
reach  the  cord,  to  feel  if  it  is  pulsating.  If  by  some 
or  all  of  these  evidences  you  think  the  child  is  dead, 
or  if  tonic  contraction  of  the  uterus  be  undoubtedly 
present,  pull  down  the  arm  and  decapitate. 

The  operations  of  version  and  decapitation  are 
described  in  the  chapters  on  those  subjects. 


77 


CHAPTER   VII. 

ON    PROLAPSE    OF    EXTREMITIES. 

Displacements  Of  arm. — The  fore-arras  should 
be  crossed  in  front  of  the  chest.  Sometimes  an  arm, 
from  causes  which  we  do  not  understand,  gets  dis- 
placed from  this  position.  It  may  lie  between  the 
head  and  neck  on  the  opposite  side,  or  on  the  same 
side,  or  be  extended  by  the  side  of  the  head,  or  it  may 
get  behind  the  neck. 

Effect  of  slight  displacement. — When  an  arm 
lies  between  the  shoulder  and  the  head,  either  on  the 
same  or  on  the  opposite  side,  it  offers  a  slight  hindrance 
to  the  descent  of  that  shoulder,  and  may  make  the 
mode  of  delivery  of  the  shoulders  different  from  that 
which  is  usual.  The  shoulder,  the  contour  of  which 
is  not  altered  by  the  presence  of  an  arm  in  contact 
with  it,  comes  down  more  readily,  and  rotates  to  the 
front.  If  the  descent  of  the  anterior  shoulder  is 
hindered,  then  the  body  of  the  child  will  make  a 
hyper-rotation,  the  posterior  shoulder  coming  to  the 
front.  The  mechanical  effect  is  interesting,  but  this 
slight  degree  of  prolapse  of  the  arm  can  hardly  be 
called  a  difficulty,  as  no  treatment  is  required, 

Descent  of  hand  with  head.— The  arm  may  be 
extended,  so  that  it  lies  by  the  side  of  the  head,  and 
enters  the  pelvic  brim  with  the  head.  If  the  head  and 
pelvis  are  of  average  size,  this  offers  no  insuperable 
difficulty  to  delivery.  But  very  often  it  goes  with 
contracted  pelvis,  for  the  head  not  fitting  the  brim 
leaves  room  for  the  hand  to  come  down  ;  and  when 
the  arm  has  come  down,  its  presence  in  the  brim  makes 
the  entry  of  the  head  more  difficult  than  it  was  before. 
Therefore,  if  you  find  an  arm  down  by  the  side  of  the 
head,  remember  that  it  may  indicate  pelvic  contraction. 
Prolapse  of  the  arm  may  also  result  from  an  oblique 


78  Difficult  Labour. 

position  of  the  child  so  that  the  head  is  slightly 
deviated  towards  one  side  of  the  brim,  leaving  room 
for  the  arm  to  come  down  in  the  opposite  side  of  the 
brim.  Uterine  obliquity  is  more  likely  to  produce  this 
effect  in  a  contracted  than  in  a  normal  pelvis.  In  a 
normal  pelvis,  the  presence  of  the  arm  opposite  a 
sacro-iliac  synchondrosis  will  make  the  head  lie  more 
transversely  than  usual. 

Treatment. — (1)  Postural.  If  the  prolapse  of  the 
arm  is  found  out  early  in  labour,  before  the  membranes 
are  ruptured,  and  appears  due  to  an  oblique  position 
of  the  foetus,  the  proper  treatment  is  to  press  the  head 
into  the  brim,  and  direct  the  patient  to  lie  on  the  side 
away  from  which  the  body  of  the  uterus  leans,  so  that 
gravity  may  correct  the  uterine  obliquity.  One  cause 
hindering  the  engagement  of  the  head  will  thus  be 
removed. 

(2)  Replacement.  If  this  be  not  successful,  or  if  the 
membranes  have  been  ruptured,  but  the  head  has  not 
descended  into  the  pelvic  cavity,  introduce  your  left 
hand  into  the  vagina,  and  with  two  fingers  press  the 
prolapsed  hand  up  and  towards  the  front  of  the  head, 
past  the  greatest  diameter  of  the  head.  If  the  pelvis 
is  natural,  the  child's  head  of  average  size,  and  the 
uterus  acting  regularly,  the  pains  will  soon  press  the 
head  so  down  into  the  pelvis  that  there  will  be  no 
room  for  the  hand  to  come  down  again. 

(3)  Turning.  But  if,  after  pushing  up  the  hand, 
the  head  does  not  come  down,  and  there  is  still  room 
between  the  head  and  the  pelvis,  so  that  the  hand 
comes  down  again,  the  probability  is  that  the  pelvis  is 
contracted,  or  the  dimensions  of  the  head  are  abnormal. 
In  such  a  case  the  best  plan  will  be  to  turn  by  the  feet 
as  soon  as  the  os  uteri  is  fully  dilated. 

(4)  Forceps.  If  the  prolapse  of  the  arm  be  not 
discovered  until  the  head  has  descended  into  the  pelvic 
cavity,  with  the  arm  beside  it,  the  fact  of  its  descent 
shows  that  the  pelvis  is  little,  if  at  all,  contracted. 
At  this  stage  of  the  labour  you  cannot  replace  the  arm. 
If  the  pains  are  strong,  let  it  alone,  and  the  head  and 


Dorsal  Displacement  of  Arm.  79 

arm  will  probably  come  through  together,  or  the  head 
may  spontaneously  be  pushed  past  the  arm.  If  there 
be  delay  in  the  delivery  of  the  head,  help  it  into  the 
world  with  forceps,  taking  care  that  the  forceps'  grasp 
does  not  include  the  arm  as  well  as  the  head. 

Dorsal  displacement. — The  arm  may  be  displaced 
behind  the  neck,  a  condition  to  which  Sir  J.  Simpson 
gave  the  name  of  "  dorsal  displacement  of  ilie  arm." 
The  arm  thus  displaced  hinders  the  descent  of  the  body, 
for  either  the  child's  body  and  the  displaced  arm  must 
come  through  the  pelvis  together,  or  the  arm  must 
be  forced  in  a  direction  contrary  to  that  of  its  natural 
movement. 

Diagnosis. — This  condition  is  very  difficult  to 
detect.  It  can  only  be  found  out  by  observing  that 
descent  is  hindered  without  any  cause  appreciable  by 
the  ordinary  methods  of  examination.  This  should 
lead  to  an  examination  with  the  whole  hand  in  the 
vagina,  and  the  other  hand  applied  outside.  Thus  a 
complete  bimanual  investigation  of  the  state  of  the 
parts  above  the  brim  of  the  pelvis  can  be  made  and 
the  position  of  the  arm  found  out. 

Treatment. — There  are  three  methods  of  treat- 
ment. One  is  to  bring  down  the  arm  by  the  side  of, 
and  towards  the  anterior  part  of  the  head.  Then  the 
case  becomes  an  ordinary  one  of  head  and  arm.  The 
second  plan  is  to  grasp  the  head  and  rotate  it  in  the 
direction  towards  which  the  fingers  of  the  displaced 
arm  point,  in  the  hope  that  the  movement  of  the  arm 
with  the  head  may  be  prevented  by  friction,  and  thus 
it  may  be  restored  to  its  proper  position  by  the  side 
of  the  child.  The  third  method  is  to  perform  podalic 
version.  These  cases  are  so  rare  that  no  accoucheur 
has  himself  seen  enough  cases,  and  not  enough  have 
been  reported,  to  enable  a  conclusion  to  be  drawn  as 
to  the  relative  merits  of  the  two  first  methods.  Sir 
J.  Simpson,  by  whom  the  first  was  recommended,  in 
a  case  in  which  he  earned  it  out,  had  afterwards  to 
turn.  In  my  opinion,  turning  is  the  safest  and  best 
method  of  dealing   with   this   difficulty.     The  hand 


8o  Difficult  Labour. 

must  be  introduced  into  the  uterus  for  the  sake  of 
diagnosis,  and  when  this  has  been  done,  the  knee  will 
not  be  far  off. 

Prolapse  of  the  feet  or  a  foot  is  practically 

merely  a  variety  of  footling  presentation,  whether  the 


Fig.  42.— Prolapse  of  Feet  with  Arms  and  Cord. 

foot  be  by  the  side  of  the  head  or  with  a  hand  or 
shoulder  (Fig.  42).  The  best  treatment  is  to  bring 
clown  one  foot  at  once. 


8i 


CHAPTER    VIII. 


ANOMALIES    OF    THE    UMBILICAL    CORD. 

Knots  in  the  COrd  are  evidences  of  the  mobility 
of  the  foetus,  because  they  are  produced  by  the  foetus 
slipping  through  a  loop  of  the  cord. 
They  may  be  formed  early  in  preg- 
nancy, and  by  subsequent  move- 
ments be  pulled  so  tight  as  to  lead 
to  atrophy  of  the  Whartonian  jelly 
at  the  places  of  pressure  (.Fig.  43). 
But  they  never  are  tight  enough 
to  interfere  with  the  circulation 
through  the  cord. 

Loops  round  child. — Often 
labour  comes  on  before  the  foetus 
has  had  time  to  slip  entirely 
through  a  loop  of  the  cord,  and  it  is 
born  encircled  with  the  cord.  The 
oldsr  the  foetus  and  the  bigger  it 
is,  the  harder  it  is  for  it  to  slip 
through  loops  in  the  cord.  Wind- 
ing of  the  cord  round  the  foetus  is 
found  in  about  1  case  in  5.  There 
is  generally  only  one  loop,  but  as 
many  as  eight  or  nine  have  been 
seen.  Both  such  winding  and  knots 
in  the  cord  usually  occur  with  very 
long  cords.  These  loops  often  en- 
circle the  neck,  and  by  compressing 
the  vessels  in  the  neck  they  may 
endanger  the  life  of  the  child.  When  the  winding 
round  the  neck  has  occurred  early  in  pregnancy,  the 
neck  has  been  found  extraordinarily  thinned  by  the 
compression.  Intrauterine  amputation  of  limbs, 
circular  grooves  in  the  limbs,  and  shrinking  in  their 
g— 36 


K.  43.  —  Atrophy  of 
Whartonian  Jelly  from 
Torsion  of  Cord. 


8a  Difficult  Labour. 

growth,  have  been  ascribed  to  the  pressure  of  loops  of 
the  cord,  although  these  effects  are  much  more  often, 
and  probably  always,  due  to  bands  of  the  amnion. 
When  twin  children  have  succeeded  in  kicking  or 
tearing  through  the  amnions  which  separate  them  in 
utero,  the  cords  may  get  intertwined  in  a  very  com- 
plicated way. 

Shortening  of  cord. — Besides  these  less  common 
effects,  twisting  of  the  cord  round  the  child  renders 
the  cord  relatively  short,  and  this  may  cause  the  same 
complications  in  labour  as  absolute  shortness  of  the 
cord.  From  all  these  occasional  effects,  it  results  that 
the  proportion  of  stillborn  and  dead  children  is 
higher  among  those  around  whom  the  cord  is  twisted 
than  in  others.  The  pressure  effects  of  loops  of  the 
cord  are  produced  during  pregnancy ;  the  effects  of  its 
shortness  during  labour. 

Shortness  Of  the  COrd. — The  cord  may  be  absent 
altogether,  the  placenta  forming  the  anterior  abdominal 
wall  (a  rare  malformation) ;  or  its  length  may  be  a  few 
inches  only.  Under  tension  it  will  stretch.  A  cord 
that  when  stretched  measures  less  than  ten  inches  will 
hinder  delivery  unless  the  placenta  is  inserted  very 
low  down.  But  a  much  longer  cord  may  be  rendered 
relatively  short  by  being  twisted  round  the  child;  and 
this  is  far  commoner  than  absolute  shortness  of  the 
cord.  If  the  cord  is  absolutely  or  relatively  so  short 
that  before  the  child  is  expelled  the  cord  is  stretched, 
the  tight  cord  will  hinder  its  advanca 

Effects. — The  following  may  be  the  results  : — 

(1)  Breaking.  The  cord  may  break.  Dr.  Matthews 
Duncan  found  that  the  breaking  strain  of  the  cord  was 
from  5^  to  15  lbs.,  and  that  it  averaged  about  8|  lbs. 
The  strongest  part  of  the  cord  is  that  near  the  placental 
insertion.  As  the  average  force  by  which  delivery  is 
completed  is  about  40  lbs.,  it  might  be  expected  that 
this  would  be  a  frequent  solution  of  the  difficulty. 

(2)  Separation  of  placenta.  It  is  presumed,  on 
theoretical  grounds,  that  the  traction  on  the  cord 
might    separate    the  placenta.     But   this   has   never 


Shortness  of  the  Cord.  83 

been  observed,  and  if  it  were  looked  for,  it  would  be 
very  difficult  to  be  sure  that  the  traction  of  the  cord 
was  the  sole  reason  of  the  detachment  of  the  placenta. 
It  is,  therefore,  believed  that  this  may  happen,  but  it 
is  not  known  that  it  has  happened. 

(3)  Inversion  of  the  uterus.  The  pull  of  the  cord 
may  invert  the  uterus.  This  is  the  way  in  which  a 
considerable  number  of  cases  of  inversion  of  the  uterus 
are  brought  about,  and  is  the  most  serious  danger 
that  shortness  of  the  cord  can  give  rise  to. 

(4)  Rotation  of  foetus.  If  the  cord  is  rendered 
relatively  short  by  being  coiled  round  the  child,  the 
child's  body  may  rotate  during  delivery  in  such  a 
direction  as  to  undo,  or  partly  undo,  the  coiling  of  the 
cord.  Such  rotation,  or  evolution,  as  Dr.  Matthews 
Duncan  termed  it,  brings  the  child's  abdomen  anterior, 
because  the  less  depth  of  the  anterior  part  of  the 
pelvic  cavity  causes  the  shortest  possible  line  between 
the  placental  and  the  foetal  ends  of  the  cord  to  be  in 
front. 

Diagnosis. — The  only  way  of  detecting  that  delay 
in  the  advance  of  the  child  is  caused  by  shortness  of 
the  cord,  is  by  feeling  the  cord,  and  perceiving  that 
with  each  slight  advance  of  the  child  during  a  pain 
it  is  made  tense. 

Treatment. — The  only  treatment  is  "to  cut  the 
cord  and  secure  the  foetal  end  with  the  fingers  until  the 
child  has  been  born,  and  then  tie  it.  When  the  case 
has  been  naturally  ended  by  rupture  of  the  cord,  it  is 
generally  broken  off  close  to  the  umbilicus,  and  the 
torn  end  of  the  artery  contracts  so  that  the  cord 
seldom  bleeds.  Should  it  bleed,  pinch  up  between 
the  finger  and  thumb  about  an  inch  of  the  abdominal 
walls,  exactly  at  the  lower  edge  of  the  umbilicus,  and 
you  will  feel  the  cord  of  the  hypogastric  arteries. 
Then  pass  a  needle  or  pin  from  side  to  side  through 
the.  abdominal  wall  underneath  the  vessels.  Your 
finger  and  thumb  will  keep  the  intestines  out  of  danger 
of  transfixion.  The  pressure  of  the  needle  will  stop  the 
bleeding.    Withdraw  the  needle  in  twenty-foui  houra 


84 


Difficult  Labour. 
Descent  op  the  Cord. 


Modes  of  descent. — Descent  means  that  the  cord 
comes  down  by  the  side  of  the  presenting  part  (Fig.  44). 
Three  conditions  are  included  under  this  term  :  Pre- 
sentation of  the  cord  (sometimes  called  chorda  praivia), 
when  the  cord  presents  at  the  os  uteri  at  the  beginning 
of  labour ;   prolapse  of  the  cord,  which  signifies  that 


Fig.  44.— Prolapse  of  Cord  by  the  Side  of  the  Head. 

the  cord  falls  downwards  when  the  bag  of  membranes 
bursts  ;  and  expression  of  the  cord,  which  means  that 
the  cord  is  squeezed  out  by  the  side  of  the  presenting 
part  later  in  the  process  of  labour.  In  the  first  two 
conditions  the  cord  can  often  be  returned,  but  in  cases 
of  expression  of  the  cord,  if  it  be  put  back  it  will  be 
squeezed  out  again  directly.  Whether  the  cord  lies 
outside  the  vulva  or  not  is  a  matter  of  no  importance. 
The  cord  usually  comes  down  at  the  sides  of  the  pelvis, 


Prolapse  of  the  Cord.  85 

seldom  either  in  front  of  the  promontory  or  behind 
the  symphysis. 

The  frequency  of  prolapse  of  the  funis  is  probably 
about  1  in  300  cases. 

When  and  why  important. — Descent  of  the 

cord  is  a  matter  of  no  consequence  to  the  life  of  the 
mother,  but  it  greatly  endangers  the  life  of  the  child, 
because  it  leads  to  the  cord  being  compressed  between 
the  head  and  the  pelvis.  When  the  child  is  born  with 
the  pelvic  end  first,  the  cord  is  always  compressed  for 
a  little  while  between  the  head  and  the  pelvis ;  but 
then  the  soft  parts  have  been  dilated  by  the  body  of 
the  child,  so  that  the  head  is  quickly  born,  and  in  a 
case  otherwise  normal  the  cord  is  not  compressed 
for  more  than  a  minute  or  two.  But  if  the  head 
presents,  and  the  cord  comes  down  by  its  side,  the  cord 
is  compressed  during  every  pain  while  the  soft  parts 
are  being  dilated  by  the  head,  which  may  take  several 
hours;  and  in  such  a  case  the  child  is  pretty  sure  to  be 
dead.  If  the  breech  presents,  there  is  plenty  of  room 
between  the  limbs  and  the  body  for  the  cord  to  lie  in 
while  the  soft  parts  are  being  dilated,  so  that  it  is  not 
pressed  on  till  the  head  comes  through.  Therefore, 
in  cases  in  which  the  head  does  not  present,  prolapse 
of  the  cord  is  a  practically  unimportant  condition. 

Causes. — Prolapse  of  the  cord  is  generally  pro- 
duced by  some  other  abnormal  condition.  In  normal 
labour  both  prolapse  and  expression  of  the  cord  are  pre- 
vented by  the  completeness  with  which  the  head  as  it 
descends  into  the  pelvis  fills  up  the  os  uteri,  so  that  the 
cord  cannot  get  past  it.  In  transverse  and  in  breech 
presentations  the  presenting  part  does  not  so  nicely 
fill  the  os  uteri  as  the  head  does.  Hence,  prolapse  of 
the  cord  is  commoner  with  these  presentations  than 
with  head  presentations.  The  conditions  which  pre- 
,  vent  the  head  from  coming  down  to  dilate  the  os 
often  cause  the  head  to  be  in  a  faulty  position ;  there- 
fore, in  face,  brow,  transverse,  and  occipito^posterior 
positions  of  the  head,  prolapse  of  the  cord  is  commoner 
than  with  the  normal  vertex  presentation  with  the 


86  Difficult  Labour. 

occiput  in  front.  Among  the  causes  which  hinder 
the  natural  presentation  and  engagement  of  the  head 
are  an  excess  of  liquor  amnii,  as  has  been  explained 
when  dealing  with  shoulder  presentations.  This  has 
an  especial  tendency  to  the  production  of  prolapse  of 
the  cord,  over  and  above  its  influence  in  preventing 
the  proper  engagement  of  the  head ;  for  when  the 
membranes  rupture  the  sudden  pouring  down  of  such 
a  quantity  of  fluid  is  very  apt  to  carry  down  with  it 
the  most  movable  of  the  solid  contents  of  the  uterus, 
viz.  the  cord.  In  twin  pregnancy  abnormal  presen- 
tations are  common,  and  therefore  prolapse  of  the 
funis  is  common. 

Contraction  Of  the  pelvis  is  a  very  frequent 
cause  of  prolapse  of  the  cord.  This  accident  has  been 
estimated  to  occur  six  times  as  often  in  contracted 
pelves  as  in  well-shaped  pelves.  About  one-third  of 
cases  of  prolapse  of  the  cord  occur  in  contracted  pelves. 
Remember  these  facts,  and  when  you  find  the  cord 
down  always  examine  carefully  the  size  of  the  pelvis. 
Contraction  of  the  pelvis  causes  prolapse  of  the  cord, 
not  only  directly,  by  preventing  the  head  from  coming 
down  into  the  os  uteri,  but  also  indirectly,  by  favour- 
ing the  production  of  abnormal  presentations.  The 
same  causes  that  lead  to  prolapse  of  the  funis  lead  also 
to  prolapse  of  the  hand  :  and  if  the  hand  come  down, 
this  will  keep  open  a  way  by  which  the  cord  can 
come  down. 

Prolapse  of  the  cord  is  rather  more  frequent  in 
multipara?  than  in  primipara,  because  in  the  former 
the  abdominal  walls  have  been  previously  stretched 
and  are  therefore  more  relaxed,  and  do  not  so  efficiently 
help  to  keep  the  presenting  part  in  the  pelvic  brim  aa 
they  do  in  patients  who  have  not  before  been  pregnant. 
Implantation  of  the  placenta  low  down  in  the  uterine 
wall,  and  of  the  cord  at  its  lower  edge,  thus  bringing 
the  uterine  end  of  the  cord  near  the  os,  has  been 
supposed  to  favour  its  prolapse ;  but  we  have  no 
evidence  in  support  of  this.  Unusual  length  of  the 
cord  must  evidently  favour  prolapse ;  but  great  length 


Treatment  of  Prolapse  of  the  Cord.     87 

of  the  cord  is  not  so  often  productive  of  prolapse  as 
might  be  expected,  because  when  the  cord  is  very 
long  it  is  usually  made  relatively  short  by  being  coiled 
round  the  body  of  the  child. 

The  immediate  cause  of  prolapse  of  the  cord  is 
generally  rupture  of  the  membranes,  the  flow  of  fluid 
carrying  the  cord  with  it. 

Diagnosis. — The  diagnosis  of  prolapse  of  the  cord 
ought  to  be  easy.  If  the  cord  be  pulsating  there  is 
nothing  with  which  it  can  be  confounded.  When 
rupture  of  the  uterus  or  vagina  has  taken  place,  and 
bowel  come  down,  the  coils  of  intestine  have  been 
mistaken  for  umbilical  cord.  It  is  difficult  to  imagine 
how  such  a  mistake  can  be  made  by  anyone  in  full 
possession  of  his  faculties,  for  the  bowel  is  attached 
by  a  mesentery,  while  the  coils  of  the  cord  lie  free. 
But  the  mistake  has  been  made. 

Prognosis. — Rather  more  than  half  the  children 
whose  cords  come  down  during  labour  are  stillborn. 
Two-thirds  of  those  that  present  with  the  head  die. 
The  post-mortem  appearances,  other  than  those  that 
may  have  been  produced  by  operative  delivery,  are 
those  of  asphyxia.  The  pressure  on  the  cord  depi-ives 
the  child  of  its  supply  of  oxygenated  blood.  The 
prognosis  is  worse  the  earlier  the  cord  comes  down. 
It  is  worse  also  the  earlier  the  membranes  burst. 
Before  the  rupture  of  the  bag  of  waters,  the  cord  is 
either  not  pressed  on  at  all,  or  only  pressed  on  during 
the  pains,  being  protected  from  pressure  during  the 
intervals  between  the  pains.  The  prognosis  is  worse 
also  if  the  cord  comes  down  in  front,  between  the 
symphysis  and  the  head,  than  if  it  descends  behind,  for 
in  the  latter  situation  it  will  be,  or  may  be,  pushed  oppo- 
site one  sacro-iliac  synchondrosis,  where  there  is  more 
room  for  it  than  in  the  conjugate  diameter  of  the  pelvis. 

Treatment :  First  stage.— (1)  Preserve  hag  of 

membranes.  The  result  for  the  child  when  the  cord 
descends  is  very  largely  dependent  upon  the  treat- 
ment. Seeing  that  while  the  membranes  are  entire 
the   cord  is  only  exposed   to  slight  and  intermittent 


88 


Difficult  Labour. 


pressure,   the  first  aim  of  treatment  is  to  keep  the 
membranes  unruptured  as  long  as  possible. 

(2)  Postural.  The  treatment  of  prolapse  of  the 
cord  before  rupture  of  the  membranes  is  very  simple. 
Jt  is,  to  put  the  patient  on  her  knees  and  elbows  (Fig. 
45).  In  this  position  the  uterus  is  nearly  vertical,  the 
os  uteri  being  the  highest  part,  the  fundus  the  lowest. 
Therefore  the  cord,  which  can  move  easily  in  the  bag 
of  membranes,  sinks  down  to  the  fundus  of  the  uterus. 


Fig.  45.—  Postural  Treatment  of  Prolapse  of  Funis. 


The  patient  should  be  kept  in  this  position  for  fifteen 
or  twenty  minutes,  to  give  the  cord  time  to  sink  to  the 
fundus.  Then  she  should  lie  on  the  side  opposite  to 
that  on  which  the  cord  came  down,  in  the  hope  that  as 
uterine  contractions  drive  the  head  down  upon  the 
cervix,  the  head  will  so  fill  it  as  to  leave  no  room  for 
the  cord  to  come  down  again.  The  patient  should 
be  kept  recumbent,  and  told  to  avoid  straining,  that 
rupture  of  the  membranes  may  be  postponed  as  long 
as  possible.  Should  the  cord  come  down  again,  the 
patient  must  be  again  put  on  her  knees  and  elbows. 
This  is  a  method  of  treatment  that  cannot  do  any 
harm.     It  not  only  gets  the  cord  away  from  the  og 


Treatment  of  Prolapse  of  the  Cord.     89 

uteri,  but  it  postpones  rupture  of  the  membranes, 
because  in  the  knee-elbow  position  the  os  being  the 
highest  part  of  the  uterus,  the  weight  of  the  bag  of 
membranes  and  its  contents,  instead  of  pressing  into 
the  os  and  thus  acting  in  the  same  direction  as  the 
force  exerted  by  uterine  contraction,  presses  towards 
the  fundus,  and  thus  opposes  the  uterine  contractions. 
Hence,  labour  goes  on  more  slowly  while  the  patient 
is  in  the  knee-elbow  position.  This  retardation  of 
labour,  and  the  possibility  that  the  patient  may  find 
the  knee-elbow  position  wearisome,  are  the  only  draw- 
backs to  this  simple  mode  of  treatment,  and  these 
drawbacks  are  not  weighty. 

After  rupture  of  the  membranes  this  simple 

mode  of  treatment  is  not  enough,  although  it  may  still 
be  found  helpful.  It  may  be  sufficient  if  employed 
soon  after  rupture  of  the  membranes,  before  all  the 
amniotic  fluid  has  escaped.  But  if  it  be  found  that 
when  the  patient  is  put  on  her  knees  and  elbows  the 
cord  does  not  go  back,  then  it  is  necessary,  for  the  sake 
of  the  child's  life,  to  do  one  of  two  things,  either 

(1)  to  put  back  the  cord ;  or 

(2)  to  deliver  quickly. 

There  are  two  exceptions  to  this  statement.  The 
first  is  when  the  cord  is  quite  pulseless,  and  the  foetal 
heart  cannot  be  heard,  so  that  it  is  clear  that  the  child 
is  dead.  (Do  not  think  that  the  child  is  dead  merely 
because  you  do  not  feel  pulsation  in  the  cord,  for  the 
circulation  through  the  cord  may  have  only  recently 
been  interrupted,  and  the  child  may  be  still  living,  and 
its  heart  beating,  although  the  blood  has  for  a  little 
while  ceased  to  flow  through  the  cord.)  If  the  cord  is 
pulseless,  listen  for  the  fcetal  heart,  and  watch  the 
state  of  the  cord  for  five  or  ten  minutes.  If  the  child 
is  dead,  there  is  nothing  to  be  gained  by  interfering. 
The  second  exception  is  when  the  pains  are  very 
strong  and  frequent,  and  it  is  certain  that  the  child 
will  be  soon  born.  Here  you  cannot  improve  upon 
matters  ;  therefore,  let  well  alone. 

Replacement  of  the  cord  is  the  ideal  method. 


go  Difficult  Labour. 

The  chief  objection  to  it  is  that  prolapse  of  the  cord 
is  generally  secondary  to  some  other  complication  of 
labour,  e.g.  contracted  pelvis;  and  if  the  cause  of  the 
prolapse  is  still  present,  the  cord  will  come  down  again. 
Many  instruments  have  been  devised  with  which  to 
replace  the  cord,  and  it  is  possible  with  some  of  these 
to  damage  the  uterus ;  as  most  of  them  have  fallen 
into  disuse,  it  may  be  inferred  that  they  are  not  of 
great  utility. 

(a)  Manual. — The  best  mode  of  replacing  the  cord 
is  with  the  hand.  An  anaesthetic  is  not  necessary, 
but  the  patient  may  wish  it.  Put  the  patient  on  her 
knees  and  elbows,  or  on  her  side  if  she  be  anaesthetised. 
Put  the  thumb  and  fingers  of  the  hand  together  so  as 
to  form  a  cone,  and  pass  the  hand  into  the  vagina.  If 
the  loop  of  cord  be  a  small  one,  take  it  between  the 
tips  of  the  fore  and  middle  fingers ;  if  it  be  a  large  one, 
in  the  palm  of  the  hand,  and  between  the  pains  carry 
it  up  past  the  greatest  diameter  of  the  head.  It  is  of 
not  the  least  use  only  to  push  the  cord  up  a  little  way, 
or  to  push  up  part  of  it ;  the  whole  of  it  must  be 
carried  past  the  largest  measurement  of  the  head.  If, 
when  this  has  been  done,  the  cord  again  comes  down, 
it  is  no  use  repeating  this  manoeuvre ;  the  only  chance 
for  the  child  is  in  speedy  delivery. 

(b)  Instrumental. — The  instruments  for  replacing 
the  cord  that  can  be  improvised  at  the  bedside  are  as 
good  as  those  specially  constructed  for  the  purpose. 
A  clean  catheter  can  be  used.  Pass  the  ends  of  a  bit 
of  string  in  at  the  eye  and  out  at  the  end,  so  as  to 
leave  a  loop  pi'ojecting  at  the  eye.  If  you  are  not 
dexterous  enough  to  do  this,  cut  a  hole  in  the  catheter 
opposite  the  eye,  and  pass  a  loop  of  tape  or  string 
through  the  two  openings.  Or  take  a  piece  of  whale- 
bone, and  with  a  gimlet  or  pocket-knife  make  a  hole 
in  it  near  one  end,  and  through  the  hole  pass  a  piece 
of  string  or  tape  so  as  to  form  a  loop.  If  your  catheter 
has  a  stilette,  withdraw  the  stilette  until  it  is  not  visible 
at  the  eye.  Then  put  a  loop  of  string  or  tape  into  the 
eye.  and  advance  the  stilette  through  the  loop  so  that 


Treatment  of  Prolapse  of  the  Cord.     91 


the  stilette  may  hold  the  loop  in  place  (Fig.  46).  Then 
tie  the  ends  cf  the  loop  together  so  as  to  form  a  ring 
in  which  the  cord  may  be  held.  Whichever  mode  you 
adopt,  having  snared  the  cord,  pass  the  catheter  up 
into  the  uterus,  carrying  the  cord  with  it.  When  the 
cord  has  been  thus  carried  up,  loosen  the  noose  if  you 
can,  or  leave  the  catheter 
in  its  place — it  will  not 
take  much  room  (Fig.  47). 
If  you  have  been  able 
to  use  a  catheter  with  a 
stilette,  withdraw  the  sti- 
lette, and  the  loop  is  free. 
These  methods  are  not 
bo  good  as  replacement 
by  the  hand.  They  bring 
with  them  a  slightly  in- 
creased risk  of  septic  in- 
fection, a  little  danger  of 
injuring  the  foetus,  uterus, 
or  placenta ;  and  a  great 
likelihood  that  the  cord 
will  come  down  again  as 
soon  as  the  replacer  has 
been  removed. 

If  reposition  fails,  the 
only  resource  is  delivery 
in  such  a  way  as  to  shorten 
the  duration  of  the  pres- 
sure on  the  cord. 

If  the  pelvis  is  normal,  and  the  head  not  of  abnormal 
size,  and  the  cord  has  simply  been  carried  down  by 
the  rush  of  the  liquor  amnii,  it  will  remain  up  if 
properly  replaced.  But  if  the  pelvis  is  contracted,  it 
will  almost  certainly  come  down  again,  however  well 
it  is  put  back. 

Indication  for  turning. — In  contracted  pelvis, 
therefore,  with  prolapse  of  the  funis,  the  best  plan  is 
to  perform  podalic  version  and  bring  down  one  leg. 
It  is  possible  that  the  cord  may  then  remain  in  the 


Fig.  46.— Cord  snared   by  Catheter 
with  Stilette. 


92  Difficult  Labour. 

recess  between  the  leg  that  remains  bent  up  and  the 
body. 

Indication  for  forceps.— If  the  first  stage  of  the 


Fig.  47.— Replacement  of  Cord  by  Catheter.     (After  R.  Barrus.) 


labour  is  near  its  end,  the  os  uteri  being  dilated  to 
three-quarters  of  its  full  size,  the  best  plan  will  be  to 
hasten  delivery  with  forceps. 


Treatment  of  Prolapse  of  the  Cord.     93 

In  short,  therefore,  in  cases  in  which  after  reposition 
the  cord  again  comes  down,  and  the  conditions  are 
not  fit  for  forceps  delivery,  turn  and  bring  down  the 
feet.  In  prolapse  of  the  funis  with  flat  pelvis,  having 
a  conjugate  diameter  of  not  less  than  three  inches, 
and  head  above  the  brim,  you  need  not  try  to  replace 
the  cord,  but  turn  by  the  feet  at  once. 


94 


CHAPTER    IX. 

TWINS. 


Usual  course  of  labour  with  twins.— Each 

twin  has  its  own  amnion,  and  generally  its  own 
chorion.  The  os  uteri  is  stretched  open  exactly  as  in 
labour  with  a  single  child  by  the  bag  of  waters  belong- 
ing to  the  twin  that  lies  lower.  When  the  os  is 
fully  dilated,  the  membranes  burst,  and  the  child  is 
born  as  in  an  ordinary  labour.  Then  the  os  uteri 
partly  recontracts.  After  a  short  interval  the  pains 
return,  the  bag  of  waters  of  the  second  child  is  forced 
on  into  the  os,  and  as  the  passage  has  been  well 
dilated  by  the  first  child,  it  yields  easily  to  the  second, 
which  is  quickly  born.  Then  the  placenta?  follow. 
The  placenta  of  the  first  child  is  not  as  a  rule  separ- 
ated from  the  uterus  till  after  the  birth  of  the  second 
child,  and  therefore  there  is  not  generally  haemorrhage 
during  the  labour. 

Diagnosis  Of  twins. — If  the  patient  is  one 
in  whom  abdominal  palpation  is  easy — that  is,  if  she 
is  not  fat,  and  i-elaxes  her  abdominal  muscles — you 
may  find  out  the  presence  of  twins  the  first  time  you 
examine  the  abdomen.  You  will  feel  two  foetal 
heads,  two  backs,  two  sets  of  limbs  ;  and  can  confirm 
the  diagnosis  by  listening  to  the  foetal  hearts.  The 
best  way  is,  of  course,  to  listen  with  a  differential 
stethoscope,  which  will  at  once  tell  you  that  the  two 
hearts  are  not  synchronous.  But  this  instrument  is 
not  usually  carried.  With  an  ordinary  stethoscope 
you  can  find  out  that  there  are  two  points — one  over 
each  foetal  back — at  which  a  fcetal  heart  is  heard 
with  maximum  loudness ;  and  you  may  appreciate  a 
difference  in  the  rapidity  of  the  two  fcetal  hearts. 

Presentations  in  twin  labour. — Abnormal 
positions  are  far  more  frequent  in  twin  than  in  nor- 


Twin  Labours. 


95 


mal  labom-,  because  when  the  presenting  part  of  one 
twin  has  got  into  the  brim,  there  is  not  room  for  the 
other  as  well  ;  and  this  twin  has  to  adapt  itself  as 
best  it  can  to  the  space  left  for  it.     The  causes  which 


Fig.  48. — Twin  Pregnancy  :  both  presenting  with  the  head. 


make  the  head  usually  present,  and  the  child  lie  with 
the  back  in  front,  act  in  twin  pregnancy  as  they  do  in 
normal  pregnancy,  and  therefore  head  presentations, 
although  they  do  not  preponderate  so  much  as  in  normal 
labour,  yet  are  still  the  most  numerous  (Fig.  48).  In 
two-thirds  of  twin  cases,  both  twins  present  with  the 
head.  Generally  the  backs  are  in  front,  and  the  two 
heads  occupy  opposite  oblique  diameters,  for  the  obvious 
reason  that  mutual  adaptation  is  thus  easier  than  if 


96  Difficult  Labour. 

they  lie  side  by  side  in  the  same  oblique  diameter. 
In  rather  more  than  one-fourth  of  the  cases  the  head 
of  one  child  and  the  breech  of  the  other  lie  together. 
In  about  one  case  in  twenty,  one  of  the  children 
presents  transversely.  Transverse  positions  during 
pregnancy  are  far  commoner  than  this,  but  often, 
after  the  birth  of  the  first  child,  the  uterine  con- 
tractions rectify  the  oblique  position  of  the  other,  and 
bring  its  head  or  breech  into  the  brim. 

Order  of  delivery. — If  one  child  lie  with  the 
head,  and  the  other  with  the  breech  over  the  pelvic 
inlet,  the  child  whose  head  is  downwards  is  usually 
born  first.  If  one  child  lie  transversely,  and  the 
other  in  the  long  axis  of  the  uterus,  the  one  in  the 
long  axis  of  the  uterus  is  the  first  to  be  born.  If  both 
lie  with  the  head  down,  and  they  are  unequal  in  size, 
the  larger  is  born  first.  The  interval  between  the 
births  of  the  first  and  second  twin  is  in  three-fourths 
of  cases  less  than  an  hour. 

Exceptional  events. —When  each  twin  is  the 
result  of  the  fertilisation  of  a  separate  ovum,  each  has 
its  own  chorion  and  placenta.  (Each  twin  always 
has  its  own  amnion,  for  this  is  a  foetal  membrane. 
Cases  in  which  the  two  foetuses  have  seemed  to  lie  in 
a  common  amniotic  cavity  are  simply  cases  in  which 
active  children  have  kicked  a  hole  in  the  membranous 
partition  formed  of  the  two  amnions.)  When  this  is 
the  case,  after  the  birth  of  the  first  child  its  placenta 
may  follow.  If  this  happen,  the  second  child  may  be 
retained  for  several  hours,  days,  or  even  weeks.  Suck 
long  retention  as  the  last  mentioned  is  very  rare,  and 
only  happens  when  the  two  ova  were  fertilised  at 
different  times,  so  that  the  growth  of  one  is  not  com- 
plete when  its  co-twin  is  expelled.  It  has  happened 
also  that  after  the  birth  of  the  first  child,  both  placenta? 
have  been  expelled.  This  is  very  rare  ;  it  only  occurs 
if  both  placenta?  are  situated  low  down  on  the  uterus 
— if  each  is,  in  fact,  nearly  or  quite  prsevia.  Placenta 
praavia  is  very  rare  with  twins,  for  reasons  given  in 
the  chapter  on  that  subject. 


Tvvin  Labours.  97 

Complications  Of  twin  labour.— In  twin  preg- 
nancy the  uterus  is  abnormally  distended  because  its 
contents  are  more  bulky  than  usual.  This  abnormal 
distension  makes  its  action  weak.  Hence  weak  pains 
are  commoner  in  twin  labour  than  in  normal 
labour.  The  uterus  becomes  sooner  exhausted  than 
in  a  normal  labour,  and  hence  uterine  inertia  in  the 
third  stage  of  labour,  with  its  consequence,  post- 
partum haemorrhage,  is  more  common  than  after 
normal  delivery.  Abnormal  presentations  bring  with 
them  the  same  effects  in  the  course  of  labour  as  in 
single  pregnancy — premature  rupture  of  membranes, 
etc. — and  expose  the  mother  to  the  same  slight  in- 
crease of  risk  from  the  necessity  for  operative  inter- 
vention. The  greater  distension  of  the  uterus  raises 
the  pressure  within  the  belly,  and  as  this  increased 
pressure  is  one  of  the  factors  which  produce  the 
kidney  disease  and  eclampsia  of  pregnancy,  these 
complications  are  commoner  in  twin  pregnancy  than 
in  normal  pregnancy.  In  about  one-fourth  of  twin 
pregnancies  labour  comes  on  prematurely. 

Duration  Of  labour. — The  duration  of  labour 
with  twins  is  not  upon  the  average  longer  than  in 
single  pregnancies,  notwithstanding  the  liability  to 
weakness  of  pains.  This  is  because  the  children  are 
generally  small,  so  that  the  soft  parts  need  not 
be  stretched  open  so  much  to  let  the  children  pass. 
The  uterus  is  weak,  but  its  task  is  easier.  The 
average  length  of  labour  is  further  abridged  by  the 
frequency  with  which,  owing  to  abnormalities  in  the 
course  of  labour,  delivery  is  artificially  hastened. 

Prognosis. — The  mortality  of  the  children,  from 
the  frequency  of  premature  labour,  of  abnormal 
presentations,  and  the  smallness  and  weakness  of  the 
children  even  if  born  at  term,  is  more  than  twice  as 
great  as  in  normal  labour.  The  prognosis  for  the 
mother  is  rather  worse,  from  the  frequency  of  the 
complications  mentioned  above. 


H— 36 


98  Difficult  Labour. 

Rules  for  delivery  in  twin  pregnancy. 

1.  If  after  the  first  child  is  born  the  membranes 
of  the  second  child  still  remain  entire,  wait  for  half  an 
hour.  If  within  that  time  the  placenta  of  the  first 
child  is  expelled,  do  not  hasten  the  birth  of  the 
second.  Wait  another  hour,  and  then,  if  no  uterine 
action  take  place,  and  there  is  no  haemorrhage,  leave 
the  patient,  and  tell  her  to  send  when  the  pains  re- 
turn. The  two  children  may,  as  has  been  explained 
above,  be  of  different  intra-uterine  age,  and  the  second 
child  may  be  retained  for  days  or  weeks. 

2.  If  half  an  hour  after  the  birth  of  the  first  child 
its  placenta  has  not  been  expelled  into  the  vagina, 
and  the  membranes  of  the  second  child  are  still  un- 
broken, find  out  how  the  second  child  is  presenting, 
and  if  it  be  with  the  head  or  breech,  rupture  the 
membranes.  If  any  other  part  present,  pass  your 
hand  into  the  uterus,  seize  a  knee  (in  doing  which 
you  will  rupture  the  membranes),  bring  it  down,  and 
deliver. 

3.  If  the  membranes  of  the  second  child  have 
already  ruptured,  manage  the  delivery  just  as  in  an 
ordinary  labour.  If  the  head  or  breech  is  advancing, 
and  pains  are  strong,  let  it  alone.  If  pains  are  weak, 
assist  by  pulling.  If  the  presentation  be  transverse, 
turn  and  extract. 

4.  In  any  case  take  more  care  than  usual  to  prevent 
post-partum  haemorrhage.  Give  a  dose  of  ergot  as 
soon  as  the  children  are  born. 

Besides  the  complications  which  may  occur  in  aiiy 
labour,  and  which  are  described  elsewhere,  there  are 
some  which  are  peculiar  to  twin  labours. 

Interlocking  Of  twins.— In  twin  labour  the 
children  may  obstruct  one  another,  in  various  ways. 

1.    When  both  lie  with  the  head  doivnward. 

Jn  this  case  it  is  possible  that  as  the  head  which 
is  in  advance  sinks  into  the  pelvic  cavity,  the  head  of 
the  second  child  may  be  driven  againstits  neck,  pinning 
it,  as  it  were,  against  the  brim  of  the  pelvis.  If  the 
children  are  small,  the  head  of  the  second  child  may 


Twin  Locking.  99 

come  through  the  pelvis   with  the  chest  of  the  gRsfc. 
If  this  does  not  happen,  help  will  be  needed.     3?htf 

fr,    f 


Fig.  49.— Showing  Interlocking  of  Twins  :  first  child 
partly  delivered  with  pelvic  end  in  advance, 
second  with  head.    (After  R.  Barnes.) 

A  b,  Plane  oX  brim;  sen,  wedge  formed  by  head  of  first  child  and  neck  of 
second. 


course  which  will  suggest  itself,  as  the  head  is  engaged 
in  the  pelvis,  is  the  use  of  forceps.     When  you  seize 


IOO 


Difficult  Labour. 


ihu  head  and  pull,  you  will  find  a  difficulty  in  bringing 
it^through  the  pelvis  or  even  making  it  move,  which 
the  absence  of  all  signs  of  impaction  did  not  lead  you 
to  expect,  and  which  you  will  be  unable  to  account 
for  either  by  the  size  of  the  head  or  the  pelvis  or  the 
soft  parts.  This  state  of  things  will  call  for  careful 
examination.  Bimanual  examination  will  reveal  to 
you  a  hard  round  globe,  the  second  head,  above 
the   one  which   you  have  grasped  with   the  forceps. 


Fig.  SO.    Showing  Interlocking  of  Twip.3;   head  of  first  child  descending 
into  pelvis,  second  child  lying  trausvjtsely.     {After  Charpentier.) 


You  may  not  at  first  form  a  correct  opinion  as  to 
what  this  globe  is,  but  when  you  have  made  out  its 
presence  the  treatment  will  be  clear,  viz.  to  push  it 
up  or  aside  if  possible,  that  the  child  whose  head 
you  have  seized  with  forceps  may  be  brought  down. 

2.  One  child  may  lie  with  the  pelvic  end,  the  othei 
with  the  head  down. 

In  this  case,  it  is  possible  that  when  the  legs  have 
been  extracted,  and  the  trunk  has  entered  the  pelvis, 
the  head  of  the  second  child  may  get  locked  below  the 


Twin  Locking.  ioi 

head  of  the  first,  preventing  it  from  coming  down. 
There  are  various  ways  of  this  locking.  The  two 
heads  may  interlock  chin  to  chin,  the  face  of  one  look- 
ing to  the  neck  of  the  other  (Fig.  49).  The  chin  of 
one  may  be  pressed  into  the  nape  of  the  neck  of -the 
other.  The  occiput  of  each  may  be  pressed  into  the 
nape  of  the  neck  of  the  other.     The  head  of  one  may 


Fig.  51.— Locking  of  Twins  :  one  foetus  partly  delivered  with  breech 
in  advance,  the  other  lying  transversely.    (After  Charpentier.) 

be  pressed  against  the  side  of  the  neck  of  the  other. 
In  this  case,  if  the  children  are  small  enough,  they 
may  both  come  through  together,  in  spite  of  the 
locking.  If  the  advance  of  the  first  child  is  hindered, 
careful  examination  will  detect  the  hard  round  mass 
which,  with  the  chest  of  the  partly-born  child,  fills  the 
pelvic  brim,  and  you  will  at  once  perceive  that  this 
is  the  cause  of  the  delay. 

In  treatment,  the  first  thing  to  be  done  is  to  see 
if  you  can  disengage  the  interlocking.     If  the  uterus 


102  Difficult  Labour. 

is  not  contracting  strongly,  you  may  be  able,  by 
pushing  up  the  partly-born  child,  to  release  the  im- 
paction, so  that  you  can  push  up  and  out  of  the  way 
the  head  of  the  second.  Supposing  that  you  cannot 
do  this,  consider  which  life  is  the  more  valuable,  that  of 
the  first  or  the  second  child  1  If  delivery  is  not  speedy 
the  first  child  is  sure  to  be  stillborn.  The  second 
child  is  therefore  the  one  which  you  have  the  best 
chance  of  saving.  The  best  treatment  is  to  sever  the 
body  of  the  first  child  from  the  head.  The  head  will 
slip  up,  and  then  with  forceps  you  can  seize  the  head 
of  the  second  child  and  deliver  it. 

3.  One  child  may  lie  transversely,  the  other  pre- 
senting either  with  the  cephalic  or  pelvic  extremity. 

In  this  case  it  is  possible,  whether  the  head 
or  breech  descend  first,  that  the  child  which  lies 
transversely  may  get  so  jammed  against  the  neck  of  the 
child  which  has  advanced  into  the  pelvis  as  to  hinder 
the  descent  of  the  shoulders  if  the  head  presented 
(Fig.  50),  the  head  if  the  breech  presented.  The  diag- 
nosis of  this  form  of  obstruction  is  only  to  be  made 
by  careful  bimanual  examination.  The  treatment  con- 
sists in  pressing  aside  the  child  which  is  obstructing 
delivery,  while  you  pull  on  the  other.  If  the  first 
child  presented  by  the  breech  or  feet,  and  the  pulsa- 
tion in  the  cord  has  ceased  so  long  that  it  is  certain 
the  child  is  dead,  the  trunk  may  be  detached,  and  then 
the  second  child  may  be  delivered  by  turning  (Fig.  51). 
But  in  this  case  decapitation  is  neither  so  necessary 
nor  so  advantageous  as  when  the  head  of  the  second 
child  is  jammed  below  the  head  of  the  first.  One 
important  rule  in  all  impactions  of  this  kind  is  to 
abstain  from  giving  ergot.  This  drug  will  kill  the 
foetus,  make  manipulation  difficult  and  dangerous,  and 
do  no  good. 


io3 


CHAPTER    X. 

MALFORMED    CHILDREN. 


Certain  malformations  of  the  child  make  delivery 
difficult.  These  will  now  be  described.  I  mention 
only  those  which  cause  difficulty  in  delivery ;  there 
are  many  others,  of  much  embryological  interest, 
but  not  important  obstetrically. 

General  enlargement  of  the  child.— Labour 

may  be  difficult  simply  because  the  child  is  of  exces- 
sive size.  Difficulty  from  this  cause  ought  to  be  pre- 
vented. If  the  patient  is  well  advised,  she  will  let 
her  doctor  examine  her  at  the  end  of  the  seventh, 
and,  if  necessary,  the  eighth  month  of  pregnancy. 
He  can  then  find  out  if  the  child's  size  is  excessive, 
and  induce  labour  before  the  child  gets  too  big.  I 
shall  explain  how  to  estimate  the  size  of  the  child 
when  I  describe  the  induction  of  premature  labour. 

In  the  early  months  of  pregnancy  the  head 
is  much  larger  as  compared  with  the  trunk  than  it  is 
at  birth,  and  at  birth  the  head  is  relatively  much 
larger  than  in  children  a  few  months  old.  In  accord- 
ance with  these  facts  we  find  that  in  children  whose 
intra-uterine  development  is  excessive,  the  shoulders 
are  larger  in  comparison  with  the  head  than  is  normal. 
With  such  a  child,  the  excessive  size  of  the  shoulders 
may  greatly  obstruct  delivery.  The  shoulders  may  be 
so  large  that  they  will  not  enter  the  brim,  and  thus 
prevent  the  head  from  being  born.  If  the  pelvic  end 
present,  the  shoulders  may  stick  in  the  brim  and 
prevent  the  head  from  coming  down. 

Attempts  have  been  made  to  get  a  mode  of 
accurately  measuring  a  part  of  the  foetus  accessible 
through  the  vagina — the  sagittal  suture,  or  a  foot, 
according  to  the  position  of  the  child — and  from  this 
to  calculate  the  size  of  the  child  :  an  application  of  the 


104  Difficult  Labour. 

proverb,  "ex  pede  Herculem."  But  at  present  the 
difficulty  of  correct  measurement  makes  this  of  no 
practical  use.  You  may  roughly  guess  from  the  size 
of  the  foot  or  the  suture  as  to  the  bulk  of  the  whole 
foetus  :  but  that  is  all. 

This  mechanical  impediment  can  only  be  found 
out  by  the  obstacle  it  causes  to  delivery.  The  os 
uteri  is  retracted,  the  head  engaged  in  the  pelvic 
cavity  and  advance  ceases.  The  head  is  not  impacted, 
and  the  forceps  can  be  easily  applied,  but  pulling  does 
not  make  the  head  advance.  If  there  is  neither  in 
the  pelvis,  nor  the  uterus,  nor  the  foetal  head  anything 
to  hinder  progress,  the  cause  of  delay  must  be  in  the 
child's  body.  The  only  thing  to  do  is  first  to  perforate 
the  head,  thus  gaining  access  to  the  chest,  and  then 
to  diminish  the  size  of  the  chest  either  by  opening 
it  with  scissors  or  by  cutting  off  an  arm.  Such 
cases  are  very  rare. 

It  is  commoner  to  find  that  after  the  head  is  born 
the  shoulders  so  tightly  fill  the  pelvis  that  their 
delivery  seems  impossible.  The  only  way  to  assist  it 
is  to  pull  during  tfAepaiwsonthehead,  and  pull  at  the 
same  time  with  a  finger  in  the  axilla.  Put  a  finger 
in  the  anterior  axilla,  and  carry  the  head  backwards, 
so  as  to  get  the  anterior  arm  under  the  pubic  arch. 
If  you  can  do  this,  by  pulling  the  head  forwards  make 
the  posterior  shoulder  sweep  over  the  perineum  ;  or 
you  can  then  disengage  the  anterior  arm.  If  you 
cannot  reach  the  anterior  axilla,  or  cannot  get  it 
down,  carry  the  head  forwards,  so  as  to  make  the 
neck  hug  the  symphysis,  and  get  your  finger  over  the 
posterior  axilla,  so  as  to  pull  it  down,  and  then  either 
by  pulling  the  head  backwards  make  the  arm  press 
back  the  perineum  so  that  you  can  get  the  anterior 
shoulder  under  the  pubic  arch  ;  or  you  may  disengage 
the  posterior  arm.  In  bringing  out  the  arms  take 
care  to  do  it  by  pressure  on  the  elbow,  not  on  the 
humerus,  for  by  the  latter  mode  you  will  veiy  likely 
break  the  arm. 

If  you  cannot  get  down  the  shoulders  with  your 


Hydrocephalus.  105 

fingers  you  may  try  the  blunt  hook.  This  instrument 
differs  from  the  finger  in  being  stronger,  and  not  sus- 
ceptible of  fatigue.  But  with  it  you  can  very  easily 
damage  the  humerus  or  the  shoulder  joint. 

If  nothing  succeeds,  perforation  of  the  chest  is  the 
only  course  that  remains  ;  but  cases  of  this  kind,  in 
which  evisceration  is  called  for,  are  infinitely  rare. 

If  the  child  has  presented  by  the  breech,  and  there 
is  great  difficulty  in  getting  the  chest  through,  eviscer- 
ation may  be  done  early  without  scruple,  because  in 
such  a  case  the  pressure  on  the  cord  is  pretty  sure  to 
kill  the  child. 

Fcetal  anasarca. — Children  sometimes  become  the 
subjects  of  general  dropsy  while  in  utero.  We  know 
very  little  of  the  causes  of  this  condition.  It  is  be- 
lieved, for  plausible  reasons,  to  be  due  (a)  to  disease 
of  the  placenta.  The  placenta  depurates  the  blood  in 
the  foetus  as  the  kidney  does  in  the  adult.  Therefore 
as  kidney  disease  in  the  adult  causes  dropsy,  so,  it  is 
thought,  placenta]  disease  causes  dropsy  of  the  foetus. 
(b)  To  anasarca  of  the  mother,  the  disease  of  the  mother 
affecting  the  foetus  also,  (c)  To  disease  of  the  heart 
or  great  vessels  of  the  foetus,  dropsy  being  produced 
just  as  it  is  by  similar  conditions  in  the  adult,  (d)  To 
syphilis.  But  with  each  of  these  conditions  which 
are  supposed  to  cause  dropsy  of  the  foetus,  it  is  the 
case  that  children  are  oftener  born  without  dropsy 
than  with  it.  Why  it  is  that  some  such  children 
should  be  dropsical  but  the  majority  not,  we  do  not 
know. 

Foetal  emphysema. — Sometimes  a  decomposing 
foetus  becomes  greatly  swollen  from  evolution  of  gas. 
Difficulty  may  thus  be  caused,  but  not  frequently  on 
account  of  the  softness  of  the  foetus. 

Treatment. — As  these  children  are  either  dead, 
or  die  soon  after  birth,  the  treatment  of  difficulty 
from  this  cause  is  evisceration. 

Hydrocephalus.  — This  is  very  rare  (Fig.  52). 
Different  statistical  tables  show  a  frequency  of  from 
1  in  1.000  to  1  in   3,000.     We  know  nothing  about 


ro6  Difficult.  Labour. 

the  causes  of  intra-uterine  hydrocephalus,  and  there- 
fore we  cannot  prevent  it.  It  does  not  produce  any 
symptoms  during  pregnancy,  and  therefore  cannot  be 
diagnosed  without  examination.  It  formidably  ob- 
structs delivery,  and  as  it  has  often  been  overlooked 
it  has  often  led  to  rupture  of  the  uterus. 

Effect  on  labour. — In  hydrocephalus  the  child 
hardly  ever  lies  transversely ;  either  head  or  breech 


Fig.  52. — Hydrocephalus  of  the  Foetus. 

presents.  Head  presentation  is  the  more  common, 
but  breech  presentations  occur  of  tener  in  hydrocephalic 
than  in  healthy  children. 

Liability  to  rupture  Of  Uterus. — Hydroce- 
phalus, when  the  head  presents,  exposes  the  mother  to 
more  danger  than  usual  of  rupture  of  the  uterus.  It 
does  this  in  two  ways.  First,  the  head  is  so  large 
that  it  cannot  enter  the  brim,  and  therefore,  if  no 
relief  is  given,  the  regular  results  of  obstructed  labour 
follow,  viz.  tonic  contraction  of  the  uterus,  ending 
either  in  death  or  uterine  rupture.     Second,  there  is 


HYDROCErHA  LUS.  I O  7 

with  hydrocephalus  a  greater  tendency  than  usual 
for  tonic  contraction  of  the  uterus  to  end  in  uterine 
rupture,  because,  owing  to  the  head  being  unnaturally 
large,  the  lower  uterine  segment  has  to  be  unnaturally 
stretched  as  the  retracting  uterine  body  pulls  the 
lower  uterine  segment  up.  Abnormal  stretching  and 
therefore  abnormal  thinning,  bring  abnormal  liability 
to  rupture. 

How  naturally  delivered. — Statistics  show  that 

the  results  of  labour  with  hydrocephalus  are  rather 
better  with  extreme  enlargement  of  the  head  than 
with  slight.  This  is  partly  because  the  extreme  cases 
are  sooner  diagnosed  and  treated.  It  is  also  partly 
because  in  extreme  cases  nature  sometimes  overcomes 
the  difficulty.  When  the  ventricular  wall  and 
calvarium  are  very  expanded  and  tense  they  are 
thinned,  and  burst  more  easily.  Then  the  fluid 
escapes  between  the  calvarium  and  the  scalp,  and 
under  pressure  readily  makes  its  way  along  the 
cellular  tissue ;  the  skull  then  collapses,  and  natural 
delivery  may  follow. 

Hydrocephalus  with  breech  presentation  seldom 
ends  fatally  for  the  mother,  because  every  accoucheur 
knows  that  it  is  no  use  prolonging  efforts  to  deliver 
the  obstructed  after-coming  head,  and  therefore  per- 
foration is  generally  performed  soon. 

Diagnosis. — The  diagnosis  of  hydrocephalus  is 
easily  made.  It  is  not  always  diagnosed  because  it 
is  rare,  and  therefore  accoucheurs  sometimes  do 
not  think  of  it.  If  the  head  is  presenting,  the  con- 
dition is  identified  by  discovering  (1)  on  abdominal 
examination  the  great  size  of  the  head,  which  lies  high 
above  the  pelvic  brim,  together  with  (2)  vaginal  examin- 
ation which  reveals  the  wide  separation  of  the  cranial 
bones  at  the  sutures  and  fontanelles.  Sometimes  this 
is  so  great  that  a  fontanelle  presenting  at  a  slightly 
dilated  os  uteri,  may  be  taken  for  the  bag  of  mem- 
branes. Hydrocephalus  of  the  after-coming  head  can 
only  be  diagnosed  by  abdominal  palpation.  But  here, 
as  has  been  pointed  out,  the  correct  line  of  treatment 


108  Difficult  Labour, 

is  usually  clear  whether  the  diagnosis  has  been  made 
or  not. 

Treatment. — The  ideal  treatment  is  to  tap  the 
dropsical  head  with  a  trocar,  draw  off  the  fluid,  dilate 
the  cervix  if  necessary  with  a  water  bag,  and  then 
perform  podalic  version  when  it  is  fully  dilated.  In 
this  way  there  is  a  slender  chance  of  a  living  child 
being  delivered,  which,  after  giving  a  great  deal  of 
trouble  to  its  mother  and  nurse,  will  probably  die 
within  a  year,  but  has  a  remote  chance  of  growing  up 
into  a  deformed  imbecile.  The  usual  treatment  (as  a 
trocar  and  cannula  are  not  generally  carried  in  the 
obstetric  bag)  is  to  perforate  and  deliver  with  the 
cranioclast  or  cephalotribe  as  soon  as  the  diagnosis  is 
made.  This  is  safer  for  the  mother,  as  there  is  a  slight 
risk  of  rupturing  the  uterus  in  introducing  the  hand 
for  turning.  The  after-coming  hydrocephalic  head  has 
been  known  to  burst  under  traction  used  for  delivery. 
The  proper  treatment  is  to  perforate  as  soon  as  it  is 
clear  that  the  head  is  so  large  that  it  cannot  be 
delivered  quickly. 

AnencephalllS. — The  commonest  monstrosity  is 
the  anencephalic  foetus.  In  this  the  cranium  is  absent 
so  that  the  base  of  the  skull  is  uncovered  by  bone. 
Sometimes  the  upper  part  of  the  spinal  canal  gapes 
also.  In  place  of  a  proper  brain,  the  base  of  the 
skull  is  filled  with  what  looks  like  granulation  tissue, 
but  is  really  imperfectly  formed  cerebral  matter. 

Anencephalic  foetuses  are  either  born  dead  or  die 
very  soon.     Life  extending  over  days  is  rare. 

There  are  three  abnormalities  in  labour  which 
commonly  go  with  anencephalic  foetuses.  The  first 
has  relation  to  the  amount  of  liquor  amnii.  More 
or  less  excess  of  liquor  amnii  is  the  rule,  we  do 
not  know  why.  The  second  has  reference  to  the 
mode  of  presentation.  If  the  defect  does  not  extend 
beyond  the  skull,  the  head  presents  in  a  position 
between  flexion  and  extension,  and  the  examining 
linger  comes  upon  the  base  of  the  skull,  covered  by 
soft  tissue  in  the  middle  of  which  the  sella  turcica 


Enlargement  of  Fcetal   Body.         109 

can  be  felt.  This  resembles  nothing  else  that  is  ever 
felt  in  a  labour  and  settles  the  diagnosis.  If  the 
defect  involves  the  upper  part  of  the  spine  as  well  as 
the  skull,   the  face  presents.     The   third  feature  is, 


Fig.  53.— Fcetus  with  Distension  of   urinary  Bladder  from  Imperforate 
Urethra.    (After  Schivyzer.*) 

that  the  shoulders  of  anencephalic  foetuses  are  often 
very  broad,  so  much  so  as  to  obstruct  delivery. 

The  treatment  of  difficult  labour  with  an  anen- 
cephalic foetus  obviously  is  embryotomy.  If  the 
shoulders  give  difficulty,  amputate  the  arm  or  per- 
forate and  empty  the  chest. 

*  Arch,  fiir  Gyn.,  Bd.  xliii. 


no  Difficult  Labour. 

Morbid  enlargement  of  the  foetal  body- 
Delivery  may  be  impeded  by  morbid  enlargement  of 
the  foetal  trunk.  The  diseases  by  which  such  enlarge- 
ment is  generally  caused  are  hydrothorax,  ascites, 
distension  of  the  urinary  bladder,  cystic  disease  of  the 
kidneys.  The  distension  of  the  belly  by  the  latter 
diseases  may  be  enormous,  so  that  the  head  and  limbs 
look  like  small  appendages  to  the  big  round  trunk' 
(Fig.  53).  Fortunately  such  very  diseased  children 
are  generally  born  prematurely. 

Foetal  ascites  is  generally,  not  always,  due  to 
syphilitic  disease  of  the  liver.  Distension  of  the 
bladder  comes  from  the  urethra  being  imperforate. 
In  cystic  disease  of  the  kidneys  these  organs  are  con- 
verted into  a  mass  of  cysts,  in  size  from  a  pin's  head 
upwards,  and  by  this  change  enlarged  ;  they  have  been 
found  weighing  several  pounds.  The  cysts  arise  by 
the  stopping  up  of  renal  tubes,  possibly  by  concretions 
of  urinary  salts. 

Children  with  swelling  of  the  cheat  or  belly  gener- 
ally present  with  the  head,  but  present  with  the 
breech  oftener  than  healthy  children  do.  Head 
presentations  are  to  breech  as  about  two  to  one.  The 
length  of  the  neck  usually  allows  the  head  to  be 
delivered,  and  then  the  swollen  chest  or  belly  sticks 
in  the  pelvic  inlet.  When  the  pelvic  end  presents,  the 
legs  are  delivered  easily,  and  then  progress  is 
arrested. 

The  diagnosis  cannot  be  made  until  the  difficulty 
in  delivery  arises.  It  is  then  made  by  excluding 
other  causes  of  obstruction. 

The  treatment  consists  in  perforating  the  trunk  at 
the  most  accessible  place,  so  as  to  diminish  its  size. 

Tumours  Of  the  fcetUS. — Congenital  swellings 
of  parts  of  the  foetus  are  met  with.  From  the  back 
of  the  head  (more  rarely  from  the  front)  an  en- 
cephalocele  or  meningocele  may  project.  From  the 
sacrum  there  may  project  a  spina  bifida.  A  tera- 
toma— that  is,  a  tumour  consisting  of  part  of  a  second 
foetus — may  be  attached  to  ■  the  sacrum.     A  similar 


Double  Monsters.  hi 

tumour  may  be  attached  to  the  jaw,  either  in  the 
neighbourhood  of  the  orbit  or  the  gums  :  this  is 
called  epignathus. 

These  tumours  are,  as  a  rule,  only  obstetrically 
important  by  reason  of  the  perplexity  they  may  cause 
the  accoucheur  in  making  out  the  position  and  presen- 
tation of  the  child.  They  are  soft  and  movable,  and 
therefore  rarely  cause  difficulty  in  delivery. 

Double  monsters. — These  monsters  consist  of 
two  foetuses  more  or  less  blended  together.  Their 
mode  of  production  does  not  come  within  the  scope 
of  this  work.  Nor  is  a  knowledge  of  their  classifica- 
tion according  to  the  kinds  of  deformity  essential  to 
the  practice  of  midwifery.  I  here  only  regard  them 
from  the  point  of  view  of  the  accoucheur. 

Obstetrically  they  may  be  divided  into  three 
classes  : — =1.  Those  in  which  one  end  only  of  the  foetus 
is  double.  2.  Those  in  which  there  are  two  foetuses 
loosely  connected.  3.  Those  in  which  there  are  two 
foetuses  closely  connected. 

1.  Those  in  which  one  end  only  of  the  foetus  is 
double.  Here  we  have  the  diprosopus  (Ms,  twice, 
rp6<ra)irov,  the  face)  with  double  face ;  the  dipygus  (™yfi, 
the  buttock)  with  double  pelvis,  and  allied  forms. 
The  kind  of  difficulty  when  the  cephalic  end  is 
double  is  like  that  due  to  hydrocephalus.  The  cephalic 
end  is  of  unusual  size,  and  if  it  will  not  pass  must 
be  perforated.  The  diagnosis  can  only  be  made  by 
careful  exploration  with  the  whole  hand.  If  the 
diagnosis  is  made  in  time,  turning  will  be  advan- 
tageous for  the  same  reason  as  in  hydrocephalus.  If 
the  pelvic  end  be  double,  then  the  kind  of  difficulty 
will  be  like  that  due  to  ascites  or  hydrothorax  ;  the 
head  will  be  delivered  and  then  the  pelvic  end  will 
stick  fast.  Careful  examination  is  the  only  way  to 
identify  the  difficulty.  The  treatment  is  to  bring 
down  the  feet  one  by  one,  or  if  you  cannot  do  that, 
to  cut  up  the  pelvis  with  strong  scissors. 

2.  The  second  group  is  composed  of  monsters  in 
which  two  foetuses  are  united  at  one  end  only,  either 


Difficult  Labour. 


at  the  head  (cranio-pagus,  irayos,  from  trtiyvvpi,  I  make 
fast),  or  the  breech  (ischio-pagus,  pygo-pagus).  In 
these  cases  the  features  are  so  far  movable  upon  one 

another  that  it  is  pos- 
sible in  cranio-pagus 
for  one  foetus  to  be 
born  with  the  breech 
presenting,  and  the 
second  to  follow  with 
the  head  in  advance. 
Hence  when  this  con- 
dition is  diagnosed, 
which  can  only  be  done 
by  careful  examination 
with  the  hand  in  the 
uterus,  a  foot  should 
be  brought  down. 
When  the  foetuses  are 
united  at  the  pelvic 
end,  one  child  can  be 
born  with  the  head  in 
advance,  and  then  the 
second  as  in  a  breech 
presentation.  Hence 
in  these  cases  the  diffi- 
culty is  little  if  at  all 
greater  than  in  an 
ordinary  i,win  labour. 
3.  The  third  group 
includes  cases  in  which  the  double  formation  is  more 
extensive  than  in  the  first  group,  and  the  union  closer 
than  in  the  second.  It  includes  the  various  kinds  of 
double-headed  monsters  (Fig,  54),  and  twins  united 
side  to  side,  back  to  back,  or  belly  to  belly.  In  these 
cases  of  large  duplication  and  close  union,  when  the 
head  or  legs  of  one  child  come  down  into  the  pelvis, 
the  other  child  may  lie  across  the  pelvis  ;  and  hence, 
if  the  monster  be  large,  delivery  be  very  difficult. 
If  the  monster  be  not  very  big  it  is  possible  that,  if 
one  of  the  heads  present,  the  second  head  may  come 


Fig.  6-1.—  Dpuble-headed  Monster. 


Double   Monsters.  113 

through  the  pelvis  along  with  the  thorax  correspond- 
ing to  the  first  head.  A  similar  mode  of  transit  is 
possible  if  a  breech  or  legs  present.  A  third  possi- 
bility is  that,  with  the  second  child  lying  transversely, 
a  process  like  that  of  spontaneous  evolution  may  take 
place. 

It  is  very  little  use  laying  down  rules  for  the 
management  of  cases  like  these,  for  they  are  hardly 
ever  diagnosed  in  time  for  a  choice  of  treatment. 
Experience  has  shown  that  the  best  way  is  lor  the 
feet  to  come  down,  and  therefore,  if  you  should 
diagnose  a  double  monster  early  in  labour,  bring  the 
feet  down.  In  practice  the  treatment  comes  to  this  : 
help  delivery  by  pulling  if  required.  If  you  cannot 
deliver  in  this  way,  and  there  is  no  obstruction  arising 
from  the  size  and  shape  of  the  pelvis,  carefully 
examine.  If  you  have  a  double  monster-to  deal  with, 
deUver  by  embryotomy. 


i—36 


U4 


CHAPTER    XL 

ABNORMAL    UTERINE    ACTION. 


In  the  foregoing  chapters  I  have  described  the 
difficulties  in  delivery  which  depend  upon  abnormal 
position  or  conformation  of  the  child  or  children.  In 
this  I  shall  describe  the  abnormalities  of  uterine 
action  which  are  associated  with  delay  in  delivery. 

What  are  natural  labour  pains  ?— For  labour 

to  be  natural,  not  only  must  the  child  be  living,  of 
not  more  than  average  size  and  weight,  and  present- 
ing in  the  most  favourable  position,  but  the  labour 
pains  must  be  normal  :  that  is,  uterine  contractions 
must  recur  with  such  force  and  frequency  that  the 
child  is  born  within  twenty-four  hours  from  the  time 
at  which  the  pains  began.  The  average  length  of 
labour  is  less  than  this.  A  labour  which  lasts  as 
long  as  twenty-four  hours  is  therefore  usually  in  some 
way  abnormal,  although  the  causes  of  delay  may  be 
too  trifling  to  call  for  interference.  Twenty-four 
hours  is  an  arbitrary  but  convenient  limit,  which 
gives  nature  time  to  overcome  the  slighter  hindrances 
to  delivery.  If  the  labour  is  natural  in  every  respect 
but  duration,  the  patient  will  not  suffer  harm  from 
protraction  for  not  longer  than  twenty-four  hours. 

The  common  abnormalities  of  pains. — Cases* 

of  lingering  labour  were  classified  by  Burns,*  as 
follows  : — 

First:  "The  pains  may  be  from  the  beginning 
weak  or  few,  and  the  labour  may  be  long  of  becoming 
brisk."  This  is  primary  uterine  inertia,  or  weak 
uterine  action. 

Second  :  "  The  pains  during  the  first  stage  may  be 
sharp  and  frequent,  but  not  effective,  in  consequence 

*   ''Principles  of  Midwifery." 


Uterine  Inertia.  115 

of  which  the  power  of  the  uterus  is  worn  out  before 
the  head  of  the  child  has  fully  entered  into  the  pelvis, 
or  come  into  a  situation  to  be  expelled."  This  is 
secondary  uterine  inertia  (Scanzoni),  temporary  pas- 
siveness  (Braxton  Hicks),  or  uterine  exhaustion. 

Third  :  "  The  pains  during  the  whole  course  may 
be  strong  and  brisk,  but  from  some  mechanical 
obstacle  the  delivery  may  be  long  prevented,  and  it 
may  even  be  necessary  to  have  recourse  to  artificial 
force."     This  is  obstructed  labour. 

In  these  sentences  the  common  forms  of  lingering 
labour  are  clearly  defined.  The  distinction  between 
them  is  of  the  utmost  importance ;  it  is  the  very 
foundation  of  sound  practice  in  midwifery.  They 
are  quite  different  from  one  another,  and  need  quite 
different  treatment.  It  is  therefore  necessary  to 
consider  them  more  fully. 

Kinds  of  uterine  inertia. — You  will  notice  that 

the  term  uterine  inertia  has  been  applied  to  two 
conditions,  distinguished  by  the  prefixes  primary 
and  secondary.  These  two  conditions  are  alto- 
gether different  from  one  another.  Let  me  point 
out  the  differences. 

Both  kinds  of  uterine  inertia  about  to  be  described 
are  often,  indeed  usually,  associated  with  other  com- 
plications of  labour.  But  for  the  sake  of  clearness  I 
assume,  in  describing  them,  that  the  labour  is  in  other 
respects  normal. 

Primary  uterine  inertia,  or  weak  pains. — 

This  means,  that  "  the  pains  are  from  the  beginning 
weak  or  few."  In  a  natural  labour,  when  the  soft 
bag  of  waters  bulges  into  the  os,  the  pains  recur  at 
comparatively  long  intervals,  and  cause  but  little 
suffering.  When  the  hard  head  comes  to  press  into 
and  more  powerfully  stretch  open  the  os,  a  greater 
reflex  effect  is  produced,  and  the  pains  become  more 
frequent  and  stronger.  As  the  head  descends  and 
dilates,  first  the  vagina,  then  the  vulva — parts  more 
richly  supplied  with  sensitive  nerves — the  pains 
follow    one    another    still    more    quickly,    and    the 


u6  Difficult  Labour. 

driving  force  of  each  uterine  contraction  is  helped 
by  powerful  expulsive  efforts  of  the  diaphragm  and 
the  abdominal  muscles.  In  a  labour  lingering  solely 
from  primary  uterine  inertia,  the  course  of  the  pains 
is  as  in  a  normal  labour ;  except  that  the  intervals 
are  longer,  the  acceleration  of  the  pains  as  the  labour 
passes  into  the  second  stage  is  less  marked  :  the  pains 
are  shorter  and  weaker,  and  are  accompanied  by  less 
vigorous  bearing-down  efforts.  The  advancing  part 
of  the  child  is  not  pressed  onwards  so  powerfully ; 
and  hence  many  pains  produce  but  small  progress. 

Physical  signs. — If  the  labour  be  delayed  solely 
by  this  cause,  there  is  no  obstruction.  With  each 
pain  the  presenting  part  of  the  child  advances,  and 
when  the  pain  goes  off  it  recedes.  The  caput  succe- 
daneum  is  slow  in  formation.  The  mother's  pulse  is 
regular,  and  not  quickened.  The  expression  of  her 
face  is  not  anxious.  Put  your  hand  on  the  abdomen, 
and  you  will  find  that  between  the  pains  the  uterus  is 
relaxed,  and  that  if,  as  is  probable,  the  abdominal 
walls  are  relaxed  also,  you  can  make  out  the  outline 
of  the  child  distinctly.  During  a  pain  you  will  feel 
the  uterus  get  hard,  and  rounded  in  shape,  and  will 
notice  also  that  the  patient  feebly,  if  at  all,  assists  the 
pain  by  bearing  down.  When  at  length  the  child  is 
born,  the  third  stage,  goes  on  in  a  perfectly  satis- 
factory manner.  The  uterine  contractions,  which 
were  too  weak  to  quickly  overcome  the  resistance  of 
the  pelvic  floor,  are  quite  equal  to  expelling  the 
placenta  and  stopping  bleeding  afterwards. 

Secondary  uterine  inertia,  or  uterine  ex- 
haustion.— Contrast  this  with  secondary  uterine 
inertia.  Here,  in  the  beginning  of  the  labour,  the 
pains  follow  one  another  as  fast  as,  and  are  quite  as 
strong,  as  usual.  The  labour  goes  on  well  at  first, 
but  good  uterine  action  does  not  continue  long  enough 
to  expel  the  child.  But  after  many  hours  of  vigorous 
action  the  uterus  gets  tired,  the  pains  get  less  frequent 
and  less  strong,  and  at  length  may  cease  altogether, 
ff  the  patient  is  let  alone  she  will  probably  sleep  for 


Uterine  Inertia.  117 

an  hour  or  two,  and  then  the  pains  will  come  back 
with  renewed  vigour.  If  she  is  too  tired  to  sleep  the 
pains  will  continue  infrequent  and  weak,  or  remain 
absent  altogether  until  she  is  rested.  Dr.  John 
Ramsbotham  *  relates  a  case  of  this  kind,  in  which 
labour  was  thus  suspended  for  sixty  hours,  and  then 
uterine  action  was  resumed,  and  labour  safely  ended. 

Practical  difference. — The  practical  difference 
between  these  two  conditions — primary  and  secondary 
uterine  inertia — is  of  the  highest  importance,  f  They 
are  these  : — In  primary  uterine  inertia  you  may  with 
advantage  help  delivery  by  pulling  ;  by  forceps  if  the 
head  present,  by  the  fingers  or  by  bringing  down  a  leg 
if  the  breech  present.  The  pulling  should  be  during 
the  pains,  not  between  them ;  strive  to  help  the 
uterine  action,  not  to  replace  it.  In  this  condition 
acceleration  of  delivery  will  save  the  mother  pro- 
tracted pain  and  fatigue. 

But  in  secondary  uterine  inertia  delivery  is  the 
worst  possible  practice,  because  it  is  certain  to  be 
followed  by  dangerous  post-partum  haemorrhage. 
Passiveness  of  the  uterus  is  of  no  consequence  while 
the  child  is  within  it  and  the  placenta  still  attached. 
But  it  is  a  most  deadly  peril  when  the  placental 
sinuses  have  been  laid  open. 

In  primary  uterine  inertia  ergot  will  stimulate 
the  uterus,  so  that  instead  of  short  contractions  at 
long  intervals,  first  more  frequent  contractions,  and 
then  a  continuous  tonic  contraction  is  produced.  In 
secondary  uterine  inertia  ergot  has  no  effect,  because 
the  nervous  power  of  the  uterus  is  exhausted.     If  the 

*  "Observations  in  Midwifery,"  vol.  i.  p.  248. 

+  I  think  it  unfortunate  that  the  term  uterine  inertia  should 
have  been  applied  to  conditions  so  different.  I  should  prefer  to 
banish  the  term,  and  call  one  "  weakness  of  pains,"  and  the  other, 
either  by  the  name  given  to  it  by  Braxton  Hicks,  viz.  "tem- 
porary passiveness  of  the  uterus,"  or  by  the  more  expressive 
name  of  "uterine  exhaustion."  But,  as  both  these  conditions 
are  comprised  in  text-books  of  repute  under  the  head  of  uterine 
inertia,  I  am  obliged  to  retain  it,  and  follow  Scanzoni  in  dis- 
tinguishing the  two  very  opposite  conditions  by  the  adjectivns 
primary  and  secondary. 


r  r 8  Diffic vlt  Labour 

child  is  dragged  away,  and  the  natural  consequence — 
post-partum  haemorrhage— follows,  ergot  is  powerless 
against  it.  The  right  way  to  treat  secondary  uterine 
inertia  is  by  giving  the  patient  sleep,  and  in  this  con- 
dition the  surest  sedative  is  opium.  Give  the  patient 
a  grain  of  opium,  il\xv  of  tr.  opii,  or  5ss  of  chloral, 
and  if  she  is  not  asleep  in  half  an  hour,  repeat  the  dose.* 
Causes  Of  weak  pains. — We  know  very  little 
about  the  causes  which  make  the  pains  weak  in 
one  woman,  strong  in  another.  "Weakness  of  pains 
does  not  depend  upon  any  condition  of  ill  health  in 
the  mother  that  we  can  identify.  In  the  last  stage 
of  exhausting  diseases  labour  is  often  quick  and  easy  j 
and  lingering  labour  from  weak  pains  is  often  seen  in 
women  who  look  robust.  Weakness  of  the  pains 
undoubtedly  depends  on  some  constitutional  peculiar- 
ity, for  it  occurs  over  and  over  again  in  successive 
labours  of  the  same  patient.  Its  production  is 
favoured  by  age  and  child-bearing,  for  it  occurs 
most  often  in  elderly  multipara?.  It  has  been  said 
that  it  runs  in  families,  that  it  occurs  in  women 
who  early  in  life  have  suffered  from  chlorosis ;  that 
it  is  frequent  in  Europeans  who  go  to  live  in  hot 
countries  ;  but  I  know  of  no  evidence  that  has  been 
brought  forward  in  support  of  these  assertions.  Some 
German  writers  say  that  it  is  due  to  a  developmental 
defect  in  the  uterus — a  view  inconsistent  with  its 
comparative  infrequency  in  first  labours.  Another 
says  that  it  is  from  fatty  degeneration,  owing  to  one 
pregnancy  following  another  too  quickly,  but  brings 

*  The  following  quotation  will  show  that  this  is  no  new 
discovery :  "I  therefore  advised  patience,  and  ordered  her  a 
carminative  clyster  and  an  opiate  draught,  with  orders  to  repeat 
the  latter  six  hours  after,  in  case  the  first  did  not  answer;  this 
was  the  method  which  Dr.  Chamberlain  (the  most  noted  practi- 
tioner in  midwifery  in  his  time  in  England)  always  pursued  where 
the  pains  were  irregular  or  weak  ;  it  being  his  opinion  that  forcing 
medicines  did  more  harm  than  good,  which  I  have  always  found 
verified  in  my  own  practice." — Giffard,  "Cases  in  Midwifery," 
London,  1734,  p.  333.  The  Dr.  Chamberlain  referred  to  was  the 
inventor  of  the  forceps.  The  quotation  shows  that  he  not  only 
knew  the  use  of  his  instrument,  but  when  not  to  use  it 


Causes  of  Weakness  of  Paixs.  119 

forward  no  proof  either  of  the  fatty  degeneration  or 
the  occurrence  in  quickly  following  pregnancies.  In 
short,  in  a  great  many  cases  we  cannot  assign  any 
reason  for  the  weakness  of  the  pains. 

Too  much  liquor  amnii  stretches  and  thins  the 
uterine  wall,  and  thus  undoubtedly  makes  the  pains 
weak.  The  contractions  being  weak  the  bag  of 
membranes  is  imperfectly  pushed  into  the  os,  and 
thus  the  reflex  stimulus  which  should  call  forth 
contractions  is  deficient.  When  the  membranes 
burst,  the  head  may  come  down  on  the  cervix,  and 
fill  it  so  that  a  great  quantity  of  fluid  is  still  retained 
and  the  uterus  cannot  grasp  the  child,  straighten  it 
out,  and  so  force  on  the  head.  In  such  cases  it  is 
an  old  observation  that  putting  in  one  blade  of  the 
forceps,  thus  keeping  open  a  channel  for  the  escape 
of  liquor  amnii,  is  often  followed  by  better  uterine 
action. 

Adhesion  of  membranes. —  Sometimes  the  mem- 
branes are  more  firmly  adherent  than  usual  to  the 
uterus.  This  will  prevent  the  bag  of  membranes  from 
moving  on  into  the  os,  bulging  into  and  stretching 
it.  This  normal  reflex  stimulus  being  wanting,  pains 
are  weak.  Put  in  your  finger,  sweep  it  round  the  os, 
and  detach  the  membranes.  Then  the  bag  will  be 
able  to  move  on  and  bulge  into  the  os ;  and  quicker 
and  stronger  pains  will  come  on. 

Temporary  weakness  and  slowness  of  pains  may 
be  produced  by  various  minor  causes.  Fulness  of 
the  bladder  is  one.  Its  effect  has  been  attributed  to 
alteration  in  the  shape  of  the  uterus,  produced  by  the 
full  bladder ;  also  to  the  full  bladder  causing  bearing- 
down  efforts  to  be  painful.  The  latter  explanation  is 
the  more  satisfactory  ;  for  it  seems  to  me  more  likely 
that  the  uterus  alters  the  shape  of  the  bladder  than 
the  bladder  that  of  the  uterus.  Whatever  the  ex- 
planation, relief  to  the  bladder  will  do  good.  This 
reflex  effect  of  a  full  bladder  in  its  normal  position 
is  a  different  thing  from  the  obstruction  to  labour 
which  sometimes  is  caused  by  fulness  of  a  displaced 


i?o  Difficult  Labour. 

bladder.  In  natural  labour,  the  uterus  pulls  up  the 
anterior  vaginal  wall,  and  with  it  the  bladder,  so  that 
this  organ  is  in  the  abdomen  iu  front  of  the  uterus  and 
above  the  pubes,  quite  out  of  the  way  of  the  child. 
Occasionally,  in  patients  who  have  suffered  from 
cystocele,  the  full  bladder  may  be  found  in  the  pelvis 
in  front  of  the  presenting  part  of  the  child,  obstruct- 
ing its  progress,  the  bladder  being  prevented  by  its 
distension  from  rising.  I  have  seen  this  ;  Dr.  Lever 
described  several  cases.*  The  treatment,  of  coux^se,  is 
to  draw  off  the  urine,  and  then  the  uterus  can  pull 
up  the  bladder. 

Fulness  of  the  rectum  is  another  cause  of  tem- 
porary weakness  of  pains.  This  is  usually  manifest 
early  in  labour ;  for  in  the  second  stage,  if  the  rectum 
be  full,  the  descending  head  squeezes  the  faeces  out 
before  it.  To  avoid  this  disagreeable  process,  as  well 
as  to  help  the  first  stage,  it  is  desirable  always  to  see 
that  the  rectum  is  cleared  out  early  in  labour. 

Emotion  will  sometimes  suspend  for  a  time 
uterine  action.  The  frequency  with  which  the 
entrance  of  the  accoucheur  into  the  room,  to  use 
a  common  phrase,  "frightens  away  the  pains,"  will 
be  familiar. 

I  have  spoken  of  the  "  pains  "  without  differentia- 
tion of  their  component  parts.  The  pains  may  be 
weak,  either  from  the  action  of  the  uterus  being 
weak,  or  from  the  auxiliary  efforts  of  the  abdominal 
muscles  being  absent  or  weak,  or  from  both  causes. 
It  makes  no  difference  as  to  the  treatment  which  of 
these  conditions  it  is  that  makes  the  parturient  forces 
weak. 

It  is  hardly  needful  to  say  that  the  amount  of 
suffering  manifest  is  no  criterion  whatever  of  the 
force  of  the  uterine  contractions. 

Relative  weakness  of  pains. — When  we  speak 

of  "weak"  or  "strong"  pains,  we  mean  weak  or 
strong   relatively   to    the   resistance    that    has  to  be 

*  See  also  a  paper  by  Sir  TV.  H.  Broadbent,  Obst.  Trans.,  vol.  v. 


Relative   Weakness  of  Pains.  121 

overcome.  The  pains  may  be  weak,  but  if  the  child 
be  very  small  it  may  be  quickly  born.  The  pains 
may  be  of  quite  average  strength,  but  the  resistance 
may  be  greater  than  usual,  either  from  great  firmness 
of  the  soft  parts,  or  from  exceptional  size  of  the  child. 
The  pains  are  too  weak  for  their  work.  This  is 
"relative  weakness  of  pains."  The  rapidity  of  labour 
depends  upon  the  relation  between  the  force  and 
frequency  of  the  pains  and  the  resistance  they  have 
to  overcome.  As  the  amount  of  resistance  is  very 
variable,  and  we  have  no  means  of  measuring  it,  we 
cannot  draw  any  hard  and  fast  line  between  weak 
pains  and  obstructed  labour.  Theoretically,  a  broad 
line  may  be  drawn.  In  normal  labour,  all  that  the 
uterus  has  to  do  is  to  stretch  open  the  soft  parts. 
With  a  normal  pelvis  and  a  foetus  of  average  size,  the 
bones  offer  no  resistance  whatever  to  delivery.  If, 
this  being  the  condition  of  the  pelvis  and  child,  the 
pains  are  unable  to  dilate  the  soft  parts  within  the 
average  limit  of  time,  they  are  weak.  If  the  progress 
of  the  child  is  hindered  by  disproportion  or  mal- 
position or  disease,  so  that  the  resistance  is  abnormal 
and  greater  force  than  usual  is  required,  then  the 
pains  are  only  relatively  weak. 

In  practice  we  cannot  draw  this  distinction  so 
clearly.  We  have  no  means  of  measuring  the  amount 
of  resistance,  or  of  dividing  that  due  to  the  bony 
pelvis  from  that  due  to  the  soft  parts.  In  extreme 
cases,  of  marked  weakness  or  marked  obstruction,  the 
differential  diagnosis  is  easy ;  but  there  are  inter- 
mediate cases  in  which  labour  is  slow,  and  it  is 
difficult  to  say  whether  the  pains  are  absolutely  or 
relatively  weak.  The  diagnosis  between  absolute  and 
relative  weakness  of  pains  is  not  so  important  as 
that  between  secondary  uterine  inertia  and  conditions 
which  resemble  it,  as  the  treatment  of  absolute  and 
relative  weakness  is  the  same,  viz.  to  assist  the  weak 
uterus  by  pulling. 

Treatment    of  weak  pains.— First  stage  of 

labour.     So  long  as  the  liquor  amnii  is  retained,  no 


122  Difficult  Labour. 

harm  whatever  comes  to  mother  or  child  from  weak- 
ness of  the  pains.  Other  concomitant  troubles  may 
be  present :  the  mother  may  feel  sick  and  be  unable 
to  take  food,  or  she  may  be  unable  to  sleep.  The 
relation  of  these  troubles  to  weak  pains  is  more  often 
that  of  cause  than  of  effect.  Support  the  patient's 
strength  by  giving  liquid  food  in  small  quantities, 
and  give  sedatives  to  enable  her  to  sleep ;  but  so  long 
as  the  first  stage  of  labour  is  going  on  naturally  in 
every  respect  save  the  weakness  of  the  pains,  do 
nothing  to  hasten  it. 

In  the  second  stage  of  labour,  if  weakness  of  the 
pains  is  the  only  cause  of  delay,  no  serious  mischief 
can  come  from  waiting.  Pains  too  weak  to  dilate  the 
soft  parts  within  the  average  time  cannot  produce 
injurious  pressure  effects.  But  the  pains  of  the 
second  stage  cause  more  suffering  and  fatigue  than 
those  of  the  first  stage  ;  and  therefore  if  the  second 
stage  is  let  go  on  for  many  hours  the  patient  will  get 
very  tired.  Secondary  uterine  inertia  may  come  on. 
After  a  sleep,  which  may  be  a  short  one,  pains  will  re- 
turn, and  the  patient  be  delivered.  But  as  it  is  a  safe 
and  easy  thing  to  help  weak  pains  by  pulling,  it  is 
good  practice,  when  the  pains  of  the  second  stage  are 
tegular,  but  weak,  to  save  the  patient  fatigue  and  pain 
by  forceps  or  by  breech  traction.  Instruments  have 
been  devised  (called  toco-dynamometers)  for  accurately 
measuring  the  strength  of  the  pains.  But  they  are 
of  no  practical  use  :  for  a  statement  of  the  amount  of 
force  the  uterus  can  exert  has  no  bearing  on  the 
length  of  labour  unless  we  know  also  the  resistance 
it  has  to  overcome.  The  only  test  of  weak  pains  that 
we  have  is  the  rough  one  of  time.  The  second  stage 
is  usually  over  in  less  than  two  hours.  If  then,  in  a 
labour  in  which  the  alternate  advance  and  recession 
of  the  head  and  the  absence  of  a  great  caput  succe- 
daneum  show  there  is  no  obstruction,  the  second  stage 
is  not  finished  in  two  hours,  you  may  presume  that 
the  pains  ai-e  weak,  and  may  give  help. 

Action    of  ergot. — In   primary    uterine   inertia 


Action  of  Ergot.  123 

ergot  is  most  useful.  It  is  a  drug  as  powerful  for 
harm  in  the  wrong  cases  as  it  is  for  good  in  the 
right  ones.  It  changes  the  natural  intermittent  con- 
fractions  of  the  uterus  into  powerful  tonic,  that  is, 
continuous,  contraction,  and  then,  if  there  is  no  ob- 
struction, delivery  is  quickly  finished.  It  does  this 
by  its  specific  action  on  the  nervous  ganglia  of  the 
uterine  muscle.  If  the  nerve  force  of  these  ganglia 
is  exhausted,  ergot  will  not  act.  Hence  it  is  of  no 
use  in  secondary  uterine  inertia.  If  the  labour  is 
delayed  not  from  weakness  of  the  pains  but  from 
obstruction,  ergot  will  put  the  patient  in  imminent 
danger  of  ruptui-e  of  the  uterus.  Further,  the  tonic 
contraction  of  the  uterus  hinders  the  circulation 
through  the  utero-placental  vessels,  thus  diminishes 
the  supply  of  oxygen  to  the  child,  and,  if  its  delivery 
is  delayed,  causes  its  death  by  asphyxia.  For  this 
reason,  ergot  should  not  be  given  early  in  the  first 
stage  of  labour,  for  then,  even  if  there  be  no  obstruc- 
tion, the  labour  will  be  so  long  that  the  child  will 
probably  die.  The  fact  that  the  child  is  in  peril  from 
this  cause  can  be  found  out  by  listening  to  the  foetal 
heart. 

Effect  of  uterine  action  on  foetal  heart  — 

The  natural  changes  which  take  place  during  a  pain 
are,  that  as  the  contraction  of  the  uterus  is  coming  on, 
the  foetal  heart  becomes  quicker.  At  the  height  of 
the  contraction  it  is  slowed.  As  the  pain  is  passing 
off  it  beats  faster  again,  and,  when  the  contraction  has 
quite  gone,  returns  to  its  natural  rate.  If  ergot  is 
given,  the  contraction  is  continuous,  does  not  pass 
off;  and  the  foetal  heart  does  not  return  to  its  natui'al 
rate.  The  heart  is  first  slowed,  then  becomes  inter- 
mittent, and  then  stops  If  you  tind  the  heart  very 
slow  and  intermitting,  you  must  deliver  at  once,  or 
the  child  wiU  be  stillborn.  If  ergot  is  given  in  the 
second  stage  of  labour,  and  the  child  is  not  quickly 
born,  there  is  probably  obstruction. 

Indications  for  ergot. — The  administration  of 
ergot  in  the  second  stage  of  labour  is  good  practice 


124  Difficult  Labour. 

only  if  it  is  certain  that  there  is  no  obstruction. 
You  may  feel  pretty  sure  of  this  (1)  if  the  labour  i! 
premature.  In  labours  before  the  end  of  the  seventh 
month  it  is  always  good  practice  (except  when  the 
pelvis  is  much  contracted)  to  give  ergot  in  the  second 
stage.  (2)  If  the  patient  has  had  easy  labours  before, 
with  children  of  full  size  and  weight;  examination 
shows  that  the  presentation  is  normal  and  the  child 
not  of  excessive  size ;  and  there  is  no  abnormal 
condition  in  the  pelvis  obstructing  delivery.  And 
if  ergot  fails  to  produce  delivery  within  half-an-hour, 
forceps  should  be  used.  You  can  fonn  an  idea  of  the 
size  of  the  child  by  palpating  the  abdomen,  and  by 
ascertaining  that  the  child's  head  has  sunk  down 
into  the  pelvis,  so  that  its  greatest  diameter  is  not 
above  the  brim,  and  yet  it  is  not  impacted.  If  the 
head  is  impacted ;  if  its  greatest  diameter  is  above 
the  brim  ;  if  abdominal  palpation  gbes  the  impression 
that  the  child  is  of  unusual  size,  ergot  ought  not  to 
be  given.  The  good  rule  is  usually  laid  down  that 
ergot  ought  never  to  be  given  in  first  labours.  This 
is  because  it  is  so  difficult  to  detect  the  minor  degrees 
of  pelvic  contraction,  also  because  the  soft  parts  in 
a  first  labour  are  so  firm  that  they  stretch  slowly, 
and  the  powerful  propulsive  force  called  up  by  ergot 
is  likely  to  tear  them. 

Other  Oxytocics.  —  Other  uterine  stimulants 
besides  ergot  have  been  recommended.  Borax, 
quinine,  pilocarpin,  digitalis,  cannabis  indica,  warm 
baths,  friction  to  the  abdomen,  electricity,  have  been 
said  to  be  oxytocics.  There  is  no  drug  which  has 
an  effect  on  the  uterus  anything  like  as  great  as 
that  of  ergot.  There  are  many  preparations  of 
ergot  ;  but  the  ordinary  Pharmacopoeia!  liquid 
extract,  obtained  from  a  good  chemist,  and  given  by 
the  mouth,  is  the  best.  Quinine  and  warm  baths  act 
on  the  uterus  indirectly,  as  food  and  sleep  do,  by 
refreshing  the  patient,  but  not  so  well.  Friction  and 
electricity  stimulate  the  uterus  a  little.  Pilocarpin. 
digitalis  and  cannabis  indica  only  do  harm. 


Obstructed  Labour.  125 

Delay  caused  by  hydramirios. — If  the  amount 

of  liquor  amnii  is  so  great  as  to  distress  the  patient 
by  its  bulk,  rupture  of  the  membranes  is  the  way  to 
give  relief.  If  it  is  not  so  great  as  this,  slowness  of 
the  labour  is  a  less  evil  than  frhe  effects  of  premature 
rupture  of  the  membranes ;  therefore,  let  the  bag  of 
membranes  dilate  the  cervix,  even  though  it  do  so 
slowly. 

Obstructed  labour. — Labour  may  be  protracted, 
not  because  the  pains  are  weak,  but  because  there 
is  a  mechanical  obstacle  to  delivery. 

This  is  obstructed  labour.  We  are  indebted  to 
Dr.  Braxton  Hicks  for  first  fully  and  accurately 
describing  the  effects  of  insuperable  obstruction  to 
delivery.  When,  either  because  the  pelvis  is  too 
small,  or  the  child  too  lai-ge  or  in  a  wrong  position, 
the  uterus  is  unable  to  expel  it,  the  rhythmical  pains 
occur  at  shorter  and  shorter  intervals,  until  at  last 
there  is  no  interval  at  all,  and  the  uterus  is  con- 
tinuously contracted  :  there  is  tonic  contraction  of  the 
uterus.  When  this  stage  is  reached  the  liquor  amnii 
has  all  escaped,  and  the  tonic  contraction  no  louger 
tends  to  expel  the  child  by  straightening  it  out  and 
pressing  down  the  part  at  the  fundus,  but  grasps  it 
and  becomes  moulded  to  it.  The  uterus  is  a  very 
large  muscle,  exerting  great  power  in  its  contraction ; 
its  contractions,  therefore,  even  when  intermittent, 
consume  much  nerve  force,  and  in  proportion  exhaust 
the  patient.  When  they  become  continuous,  they 
exhaust  the  patient  still  faster.  The  length  of  time 
after  which  exhaustion  comes  on,  differs  in  different 
women ;  the  difference  depends  upon  the  nervous 
tone  of  the  patient,  not  upon  the  muscular  power 
or  the  state  of  her  tissues.  As  the  uterine  con- 
tractions do  not  generally  follow  one  another  with 
extreme  rapidity  until  they  are  excited  by  the  reflex 
effect  of  the  presence  of  the  head  in  the  cervix  or 
vagina,  tonic  contraction  of  the  uterus  seldom  comes 
on  until  the  second  stage  of  labour.  It  may  occur  in 
the  first  stage,  but  is  then  not  only  rarer,  but  more 


126  Difficult  Labour. 

slowly  produced.  It  most  quickly  comes  on  when  the 
head  is  in  the  pelvic  cavity,  because  then  the  surface 
pressed  on  is  lai'ger,  therefore  more  nerves  are  com- 
pressed, and  they  are  compressed  more  powerfully, 
being  squeezed  between  the  head  and  the  pelvic  bones. 
The  result  is  exhaustion  of  the  mother,  not  only  by 
muscular  exertion  and  pain,  but  by  bruising  and 
perhaps  sloughing  of  soft  parts  nipped  between  the 
head  and  the  pelvic  bones.  •  The  fact  that  the  symp- 
toms come  on  just  the  same  when  the  head  is  not 
presenting,  and  therefore  the  soft  parts  are  not  subject 
to  destructive  pressure,  shows  that  the  muscular  effort 
and  pain  are  the  chief  agents  in  prostrating  the  patient, 
and  that  pressure  on  the  soft  parts  plays  a  minor  part. 
The  uterine  nerves  come  mainly  from  the  sympathetic, 
the  system  of  nerves  which  most  directly  influences 
the  vital  processes. 

Symptoms. — The  symptoms  of  exhaustion  which 
accompany  tonic  contraction  of  the  uterus  are  slow 
and  insidious  in  their  approach.  The  first  symptom 
is  that  the  expression  of  the  face  becomes  anxious; 
then  the  pulse  gets  quicker  and  smaller.  The  patient's 
breathing  is  hurried  in  proportion  to  the  pulse.  Her 
tongue  becomes  first  creamy,  then  yellow,  then  brown. 
Her  lips  get  parched.  She  becomes  restless.  There 
may  be  vomiting.  If  the  patient  is  not  delivered, 
these  symptoms  get  more  and  more  marked  until  she 
dies.  Dr.  Hicks  has  found  the  tonic  uterine  con- 
traction persist  up  to  within  a  few  minutes  before 
death. 

Treatment. — When  tonic  contraction  of  the 
uterus  has  begun,  immediate  delivery  is  the  only 
treatment.  Every  hour  adds  to  the  danger  ;  and  the 
danger  of  delay  is  greater  the  farther  the  labour  has 
advanced.  Dr.  Hicks  estimates  that  the  danger  from 
delay  when  the  head  is  in  the  pelvic,  cavity  is  ten  or 
twelve  times  greater,  and  when  it  is  impacted  at  the 
outlet  eighteen  to  twenty  times  greater,  than  when  it 
is  still  in  the  uterus. 

Obstructed    labour   may    end   in    rupture  of   the 


Diagnosis  of  Obstructed  Labour.  127 

uterus  either  before  or  after  uterine  contraction  has 
become  tonic.  The  mode  of  production  of  this  accident 
I  shall  describe  in  a  subsequent  chapter. 

Importance  of  diagnosis  between  uterine 
inertia  and  tonic  contraction  of  the  uterus. 

— One  of  the  greatest  practical  blunders  that  can  be 
made  is  in  the  mistaking  tonic  contraction  of  the 
uterus  for  secondary  uterine  inertia,  otherwise  called 
temporary  passiveness,  and  the  reverse.  Therefore 
pay  careful  attention  to  the  diagnosis  between  tonic 
contraction  of  the  uterus  and  secondary  uterine  iner- 
tia. Tonic  contraction  of  the  uterus  and  secondary 
uterine  inertia  present  certain  superficial  resemblances. 
In  both,  regular  pains  have  ceased.  In  both,  the 
patient  and  her  friends  may  think  the  labour  has 
lasted  too  long,  and  be  clamorous  for  delivery.  But 
yet  the  diagnosis  between  them  is  of  extreme  import- 
ance, for  the  treatment  is  diametrically  opposite.  In 
tonic  contraction  of  the  uterus  immediate  delivery  is 
absolutely  necessary  :  in  secondary  uterine  inertia  it 
is  the  worst  possible  practice,  for  it  ensures  post- 
partum haemorrhage.  Therefore,  I  give  the  differen- 
tial diagnosis  in  a  tabular  form. 

The  points  of  difference  are  as  follows  : — 
Secondary  uterine  inertia, 

otherwise  called  Tonic  contraction 

temporary  passiveness,  of  uterus, 

and  uterine  exhaustion. 

A.     As  to  the  patient's  general  condition. 

Expression    placid :     at    most        Expression   of   face  tired   and 
snowing    signs    of    fatigue :  anxious, 

not  anxious. 
Pulse  not  over  100.  Pulse  small  and  quick  ;  gener- 

ally 120  or  over. 
Breathing  not  hurried.  Breathing  hurried  in   propor- 

tion to  pulse. 

B.     Abdominal  examination. 

Uterus  not  tender.  Uterus  tender  if  condition  has 

lasted  long. 
Or.tline  and  limbs  of  child  can        Outline  of  child  cannot  be  felt, 
be  distinctly  felt,  and  child  but  only  that   of  hard   and 

moved  about.  immovable  uterus  :  irregular 

in  shape  because  moulded  to 
the  shape  of  the  child. 


128  Difficult  Labour. 

C.     Vaginal  examination. 

Presenting  part  can  be  pushed  Presenting     part    cannot     be 

up  easily.  pushed  up. 

Caput  succedaneum  small,  so  If  head  in  pelvic  cavity,  great 

that  sutures  can  be  felt.  caput  succedaneum,  so  that 

sutures  cannot  be  felt. 

Little  or  no  swelling  of  vagina  If  head  in  cavity  vagina  and 

and  vulva.  vulva  swollen. 

Remember  also  the  contrast  in 
D.     Treatment. 

Give  the  patient  sleep  :  do  not        Deliver  without  delay, 
deliver  her. 

In  tonic  contraction  of  the  uterus  ergot  ought 
never  to  be  given,  because  its  effect  is  to  cause  this 
condition  and  increase  it  when  present. 

Prevention. — You  ought  never  to  allow  the 
uterus  to  get  into  a  state  of  tonic  contraction.  The 
conditions  which  lead  to  insuperable  obstruction  ought 
to  be  found  out  quite  early  in  labour :  for  they  are 
easy  to  ascertain.  Contraction  of  the  pelvis,  great 
enough  to  prevent  the  delivery  of  a  living  child, 
ought  to  be  noticed  when  you  make  your  first 
examination,  and  if  suspected,  the  pelvis  should  be 
measured.  A  transverse  position  of  the  child  ought 
to  be  found  out  and  corrected  early  in  labour.  If 
the  child,  or  part  of  it,  be  so  large  with  i-elation  to 
the  pelvis  that  it  cannot  enter  it,  this  ought  to  be 
ascertained  early  in  the  labour :  and  if  it  be  certain 
that  the  child  cannot  pass  through  the  pelvis,  the 
alternatives  of  embryotomy  or  Csesarian  section  should 
be  put  before  the  patient :  and  the  mode  of  delivery, 
upon  which  she,  with  the  help  of  your  advice,  decides, 
should  be  carried  out  without  delay. 

Premature  uterine  retraction.  —  The  three 

above  described  are  the  common  varieties  of  lingering 
labour.  There  is  another  kind,  first  described  by  Litz- 
mann,*  and  brought  before  English  readers  by  Mat- 
thews Duncan. f  This  condition  is  rare.  I  have  seen 
one  case.     It  occurs  chiefly  in  young  primiparae,  of 

*  Arch,  fur  Oyn.,  Band  x.  t  Obst.  Journal,  vol.  v. 


Premature  Uterine  Retraction:        129 

nervous  temperament.  The  uterus  is  morbidly  active. 
Its  retraction  goes  on  with  injurious  rapidity.  The 
intermittent  contractions  are  of  ordinary  duration,  and 
force  complaints  from  the  mother ;  but  they  are  ineffi- 
cient, and  may  justly  be  called  spasmodic.  Contraction 
of  the  uterine  body,  and  stretching  and  thinning  of 
the  cervix  and  lower  uterine  segment,  go  on  as  in 
obstructed  labour.  The  uterine  body,  which  at  the 
beginning  of  labour  covered  the  whole  foetus  down  to 
the  brim  of  the  pelvis,  becomes  a  mere  cap  or  dome- 
like covering  of  the  part  of  the  foetus  which  is  at 
the  top  of  the  uterus.  Its  fundus  is  higher  in  the 
abdomen  than  it  otherwise  would  be  (because  the 
child  is  straightened  out,  but  not  driven  down),  and 
extends  downwards  over  the  foetus  only  to  two  or 
three  finger-breadths  below  the  navel,  or  even  less. 
The  pains  are  severe,  but  inefficient.  The  head  may 
in  such  a  case  be  found  near  the  perineum,  and  be 
delivered  with  ease.  After  the  child  is  born  the 
placenta  is  easily  expelled,  and  haemorrhage  is  very 
unlikely.  The  bearing  down  efforts  are  either  un- 
affected or  powerful.  The  main  feature  is  that  the 
ring  of  Bandl  (see  chapter  xx.)  is  quickly  raised  to 
near  the  umbilicus  as  labour  goes  on,  its  hard  edge 
marking  the  limit  between  the  part  of  the  uterus 
which  contracts  and  that  which  stretches.  The  body 
above,  hard  and  firm,  allows  nothing  to  be  felt  through 
it  while  the  pain  lasts ;  the  cervix  below,  thin  and 
tight  during  a  pain,  and  even  then  allowing  foetal 
parts  to  be  felt  through  it.  This  retraction  of  the  body 
and  stretching  of  the  cervix  is  the  same  thing  as  occurs 
in  obstructed  labour,  but  there  is  no  obstruction.  The 
morbid  condition  is  that  retraction  is  premature.  In 
these  cases  ergot  will  do  harm  by  increasing  the  re- 
traction of  the  body.  If  the  conditions  are  favourable, 
delivery  by  forceps  or  breech  traction  is  indicated ; 
if  not,  opiates  or  chloroform. 

There  are  other  anomalies  of  the  pains  which  need 
mention. 

Absent  Uterine  Retraction.— I  have  seen  and 
j- 36 


130  Difficult  Labour. 

published  a  case  in  which  delivery  was  delayed  by 
absence  of  uterine  retraction.  The  labour  was  pre- 
mature :  the  pelvis  normal,  the  child  small,  the  soft 
parts  were  fully  dilated,  Champetier's  bag  having  been 
used.  For  more  than  twenty-four  hours  the  uterus  went 
on  regularly  contracting,  but  not  the  least  advance  took 
place,  although  there  was  nothing  to  hinder  the  im- 
mediate expulsion  of  the  child.  After  each  contraction 
the  uterus  relaxed  again  to  its  former  dimensions. 
In  such  a  case  the  important  point  is  not  to  deliver  : 
if  you  do  you  will  have  post-partum  haemorrhage. 
Wait  for  retraction  to  begin,  and  then  deliver. 

Partial  contraction  of  the  uterus. — This  is 

believed  to  occur,  for  the  following  reasons  : — First, 
the  placental  site  has  been  observed  after  delivery 
much  thicker  than  the  rest  of  the  uterus,  and  it  has 
been  supposed  that  this  thickening  was  due  to  local 
contraction  of  the  uterus  at  that  part.  In  my  opinion 
it  is  explained  by  the  greater  vascularity  of  the 
uterine  wall  where  the  placenta  is  attached.  Second, 
when  the  hand  has  been  introduced  into  the  uterus 
during  labour,  a  ring  of  narrowing  has  been  felt, 
which  has  been  called  a  stricture,  and  been  supposed 
to  be  due  to  a  localised  contraction  of  a  circular  ring 
of  uterine  tissue.  Such  strictures  are  not  found  in 
normal  labour.  They  occur  with  transverse  or  breech 
presentations,  with  contracted  pelvis,  with  tonic  con- 
traction of  the  uterus.  In  the  first  case  the  apparent 
stricture  is  the  imperfectly  dilated  internal  os.  The 
membranes  protrude  through  the  os;  and  before  the 
os  is  fully  dilated,  the  portion  of  the  bag  of  membranes 
which  bulges  through  it,  not  being  protected  by  the  pre- 
senting part  from  the  full  pressure  within  the  uterus, 
may  become  so  big  that  it  fills  the  vagina,  and  gives 
the  attendant  the  impression  that  the  os  is  fully 
dilated.  If  now  the  membranes  rupture,  a  so-called 
stricture  is  felt.  In  a  breech  presentation  the  breech 
may  come  down  through  an  imperfectly  dilated  os, 
which  will  not  let  the  head  pass,  and  then  the  head 
seems  to  be  detained  by  a  stricture.     These  events  are 


Precipitate  Labour.  131 

especially  likely  to  happen  in  premature  labours,  in 
which  the  cervix  dilates  badly.  In  obstructed  labour 
the  liquor  amnii  gradually  drains  away — or,  rather,  is 
expelled — so  that  when  the  uterus  gets  into  a  state 
of  tonic  contraction,  hardly  any  liquor  amnii  is  left, 
and  therefore  the  uterus  must  closely  embrace  the 
child  and  adapt  itself  to  the  foetal  outline  ;  and  then 
at  the  parts  where  the  circumference  of  the  child  is 
small,  there  seems  to  be  a  stricture. 

The  so-called  strictures  are  thus  produced,  not 
by  partial  contraction  of  the  uterus,  but  by  imper- 
fect dilatation,  or  by  an  abnormal  condition  of  the 
uterine  contents.  In  shoulder  presentation  the 
shoulder  may  get  caught  below  an  imperfectly 
dilated  internal  os,  and  thus  difficulty  in  version 
be  caused. 

The  treatment  of  these  strictures  depends  upon 
their  cause.  There  is  no  such  thing  as  a  labour, 
in  all  other  respects  natural,  being  delayed  by  a 
stricture  of  the  uterus  or  by  partial  contraction  of 
the  uterus. 

Precipitate  labour. — Precipitate  labour  means 
labour  which  goes  on  too  fast.  As  a  general  rule,  the 
quicker  the  labour  the  better  for  the  patient.  There 
ai*e  two  ways  in  which  the  labour  may  seem  too 
quick. 

1.  Apparently  precipitate. — In  a  patient  whose 
sensibility  to  pain  is  not  acute,  the  labour  may  go  on 
with  so  little  pain  that  she  does  not  know  how  far  labour 
has  advanced,  and  delivery  suddenly  takes  place  before 
she  expects  it.  The  patient  may  be  delivered  while 
standing,  or  while  sitting  on  the  closet.  The  child  may 
be  injured  by  the  fall.  If  the  cord  is  so  short  that  the 
drop  of  the  child  makes  it  tense,  it  usually  breaks  off 
at  its  weakest  part — that  is,  close  to  the  umbilicus ; 
the  vessels  retract  and  haemorrhage  is  stopped.  But 
if  the  cord  is  strong  and  the  uterus  lax,  the  sudden 
pull  on  the  cord  may  invert  the  uterus.  The 
only  way  to  prevent  these  accidents  is  by  observing 
the   rule   always    to   go    as   soon   as   sent  for.     The 


132  Difficult  Labour. 

fault  here  is,  not  that  the  pains  are  abnormal,  but 
that  the  patient  does  not  know  how  far  labour  has 
advanced. 

2.  Precipitate  labour,  properly  so-called  ;  in  which 
the  pains  recur  with  unusual  frequency  and  strength, 
so  that  the  child  is  born  more  quickly  than  usual.  The 
only  ill  result  of  such  vigorous  action  is  that  the  peri- 
neum is  more  likely  to  be  torn,  because  the  rapidly- 
propelled  head  stretches  it  too  suddenly.  The  way  to 
prevent  tearing  is  to  press  on  the  head  and  keep  it 
back,  so  that  the  stretching  of  the  perineum  may  be 
gradual.  At  the  same  time,  tell  the  woman  not  to 
bear  down,  and  take  away  from  her  everything  that 
she  can  catch  hold  of  to  help  the  straining.  The  effect 
of  too  violent  pains  may  be  further  counteracted  by 
putting  the  patient  on  her  elbows  and  knees,  so  tha.t 
the  weight  of  the  child  may  act  in  opposition  to  the 
pains.  Lastly,  the  action  of  the  auxiliary  forces  may 
be  suspended  by  chloroform. 


*33 


CHAPTER  XII. 

THE    COMMON    FORMS    OF  CONTRACTED    PELVIS. 

Difficult  labour  often  depends  on  deformity  of  the 
pelvis,  so  that  the  bony  canal,  through  which  the  child 
has  to  pass,  is  smaller  than  it  should  be. 

In  this  and  the  following  chapters  I  shall  describe 
the  kinds  of  pelvic  contraction,  their  effect  on  labour, 
their  diagnosis,  and  the  treatment  of  labour  with 
them.     The  first  question  that  arises  is — 

What  is  a  contracted  pelvis  ? — The  answer  is, 

a  pelvis  which  alters  the  course  of  labour.  In  a  labour 
in  which  the  pelvis  and  the  foetus  are  of  average  dimen- 
sions the  pelvis  offers  no  hindrance  to  the  progress  of 
the  foetus.  If  the  pelvis  is  so  small  that  the  foetus 
can  only  pass  through  it  in  a  certain  way,  delivery 
will  be  delayed  while  the  head  (the  largest  part  of  the 
foetus)  is  getting  into  the  position  most  suited  to  its 
transit.  The  pelvis  alters  the  course  of  labour,  and 
thus,  from  an  obstetric  point  of  view,  it  is  contracted. 
The  same  effect  in  labour  is  produced  if  the  foetus  is 
too  large ;  but,  as  here  the  pelvis  is  not  in  fault,  we 
do  not  speak  of  it  as  contracted.  In  speaking  of  the 
effect  of  contracted  pelvis  upon  labour,  we  assume  that 
the  foetus  is  of  average  size  and  normal  conformation. 
The  most  important  diameter,  and  the  one  most 
easily  ascertained,  is  the  conjugate,  which  measures,  in 
normal  pelves,  from  four  inches  to  four  inches  and  a 
half.  What  amount  of  diminution  in  the  conjugate, 
then,  amounts  to  contraction  of  the  pelvis  1  The 
biparietal  diameter  of  the  head  averages  three  inches 
and  three  quarters.  When  the  head  is  in  the  first 
position,  the  measurement  that  occupies  the  con- 
jugate is  one  from  a  point  in  front  of  the  left  paiietal 
bone  to  a  point  behind  the  right,  and  this  measure- 
ment  amounts    to    about    four    inches.        If,    then, 


134  Difficult  Labour. 

the  conjugate  measures  only  three  inches  and  three 
quarters,  it  will  alter  the  mechanism  of  labour,  and 
the  pelvis  may  be  considered  contracted.  If  the  con- 
traction is  not  confined  to  the  conjugate,  but  affects 
other  diameters  as  well,  there  will  be  an  effect  on 
labour  with  a  less  degree  of  contraction  of  the  con- 
jugate. With  a  conjugate  of  four  inches  and  an  oblique 
and  transverse  of  four  inches  and  a  half,  it  will  be  im- 
possible for  the  head  to  pass,  unless"fiexion  be  extreme, 
for  imperfect  flexion  will  bring  the  occipitofrontal 
(four  inches  and  a  half),  or  a  diameter  near  it,  into 
the  pelvis,  and  (as  the  bony  measurement  is  lessened 
by  the  thickness  of  the  soft  parts)  there  will  be  dif- 
ficulty. Hence  a  generally  contracted  pelvis  with  a 
conjugate  of  four  inches  must  be  considered  a  con- 
tracted pelvis. 

Clinical  classification  of  contracted  pelvis. 

— Pelvic  deformities  may,  from  a  clinical  point  of 
view,  be  divided  into  two  groups — the  common,  which 
anyone  who  for  some  years  has  a  large  midwifery 
practice  is  sure  to  meet  with  ;  and  the  rare,  which  one 
to  whom  difficult  cases  are  not  specially  sent  will  pro- 
bably never  see.  Of  course,  a  general  practitioner  may 
meet  one  of  these  rare  deformities ;  but  they  are  so 
much  less  numerous  than  doctors  that  the  chances  are 
against  it.  The  common  forms  are  the  slighter,  but  the 
more  important,  for  in  the  slight  forms  the  life  of  the 
child  and  the  well-being  of  the  mother  depend  on  the 
way  the  labour  is  managed,  while  the  diagnosis  and 
choice  of  treatment  are  often  difficult.  The  greater 
deformities,  on  the  other  hand,  force  themselves 
on  your  attention,  and  dictate  their  treatment  at 
once. 

The  common  kinds  of  contracted  pelvis  are  three 
in  number — two  kinds  of  slight  deformity,  one  of 
great  deformity.  The  common  kinds  of  slight  de- 
formity are  the  flat  pelvis  and  the  generally  contracted, 
or,  as  I  shall  call  it,  the  small  round  pelvis;  the 
common  kind  of  great  deformity  is  the  small  rickety 
pelvis. 


Production  of  Shape  of  Pelvis. 


i35 


You  will  understand  the  deformities  better  if  you 
follow  the  mode  of  their  production. 

Forces  regulating  the  shape  of  the  pelvis. 

— The  shape  of  the  pelvis  is  determined  by  three 
factors : — 

1.  The  tendency  of  the 

bones  to  grow  into 
their  proper  shape. 

2.  The  pressure  down- 

wards of  the  weight 
of  the  trunk  on 
the  sacrum,  and 
the  counter  pres- 
sure upwards  of 
the  femora  on  the 
acetabula. 

3.  The     pull     of    the 

muscles  and  liga- 
ments attached  to 
the  pelvic  bones. 
Most  pelvic  deformities 
result  either  from  (1)  soft- 
ness of  the  bones  from  dis- 
ease, making  them  yield 
to  pressure  and  pulling, 
or  from  (2)  faults  in  de- 
velopment, which  alter  the 
shape  of  the  bones,  and 
therefore  alter  the  way  in 
which  the  pressure  and  pulling  act  on  them.  The 
mode  in  which  each  deformity  is  produced  can 
generally  be  understood  by  studying  the  directions  of 
pressure  and  pulling. 

Changes  in  the  shape  of  the  pelvis  during 

growth. — The  influence  of  these  forces  is  seen  in  the 
change  in  the  shape  of  the  pelvis  which  takes  place 
during  growth.  The  foetal  spine  is  almost  straight, 
and  so  is  the  sacrum  (Fig.  55).  Hence  there  is  hardly 
any  projecting  promontory,  and  the  junction  between 
the  spine  and  the  sacrum  is  high  above  the  pelvic  brim. 


Fig.  55.— Pelvis  of  Foetus  at  Term 
{After  Balandin.) 


*36 


Difficult  Labour. 


The  sacrum  is  narrower,  for  its  lateral  masses  are 
small  at  birth.  The  whole  pelvis  is  narrow  trans- 
versely and  more  funnel-shaped,  the  tubera  ischii 
being  closer  together  than  at  birth.  During  growth 
(1)  the  pressure  of  the  body 
weight  presses  the  sacrum 
downwards  (Fig.  56) ;  (2) 
the  femora  press  the  ace  ta- 
bula upwards;  (3)  the  growth 
of  the  lateral  masses  of  the 
sacrum  and  of  the  hinderpart 
of  the  ilia  widens  the  pelvis. 
As  the  line  along  which  the 
upward  pressure  of  the 
femora  on  the  acetabula  acts 
is  outside  the  line  of  trans- 
mission of  the  body  weight 
from  the  sacral  promontory 
to  the  feet,  the  pressure  of 
the  femora,  if  unopposed, 
would  press  the  acetabula 
outwards,  and  separate  the 
innominate  bones  from  one 
another.  But  this  outward 
pressure  is  opposed  by  the 
ligaments  which  bind  the 
pubic  bones  together  at  the 
symphysis.  Divide  the  sym- 
physis in  a  cadaver  and  press 
the  thighs  upwards,  and  you 
will  separate  the  pubic  bones. 
There  is  a  malformation  (the 
split  pelvis,  see  page  243)  in  which  the  pubic  sym- 
physis is  not  united  ;  and  in  this  the  femora,  instead 
of  pressing  the  innominate  bones  together,  force  them 
apart,  so  that  there  is  a  wide  gap  at  the  symphysis 
pubis. 

Mode  of  production  of  the  common  pelvic 

deformities. — The  change  in  the  shape  of  the  pelvis 
during  growth   may  be  (1)   less,  or  (2)  more,   than 


Fig.  56.— Pelvis  of  Adult 
(After  Balandin.) 


The  Flat  Pelvis.  137 

usual,  and  in  either  case  one  of  the  common  forms  of 
slight  pelvic  contraction  is  produced. 

1.  It  may  be  less  than  usual.  The  sacral  pro- 
montory may  be  less  pressed  down  than  usual,  and 
the  widening  of  the  pelvis  less.  Then  we  have  the 
generally  contracted  pelvis — a  cumbrous  name  which, 
in  the  following  pages,  I  replace  by  that  of  the  small 
round  pelvis. 

2.  It  may  be  more  than  usual,  the  promontory  of 
the  sacrum  being  pressed  more  down  and  forward  than 
normal.     Then  we  have  what  is  called  the  flat  pelvis. 

These  two  forms  are  the  commonest.  As  the 
bones,  except  for  these  small  developmental  faults,  are 
normal,  the  deformity  is  only  slight. 

The  next  most  common  cause  of  pelvic  contraction, 
and  the  commonest  cause  of  great  deformity,  is  soften- 
ing of  the  bones  from  rickets.  This  softening  makes 
the  bones  yield  more  to  the  body  weight ;  hence  the 
deformity  is  like  that  of  the  flat  pelvis,  but  greater  in 
degree,  and  accompanied  with  signs  of  yielding  to- the 
pull  of  muscles  and  ligaments.  Rickets  often  causes 
stunting  of  growth,  as  well  as  softening  of  bones. 
Hence  rickety  pelves  are  often,  but  not  always,  small. 
According  to  whether  this  stunting  is  present  or  not, 
we  have  two  forms  of  rickety  pelvis — (1)  the  rickety 
flat  pelvis,  (2)  the  rickety  flat  and  generally  contracted 
pelvis.  For  brevity,  these  may  be  spoken  of  as  the 
rickety  pelvis  and  the  small  rickety  pelvis. 

These  are  the  common  kinds  of  contracted  pelvis. 

The  flat  pelvis. — The  commonest  form  is  the  flat 
pelvis.  When  there  is  no  other  change  but  flattening, 
it  is  called  the  simple  flat  pelvis.  In  the  following 
pages  this  form  is  meant  when  the  "  flat "  pelvis  is 
spoken  of.  From  a  clinical  point  of  view  the  size  is 
the  only  important  character.  Great  flattening  is 
almost  always  rickety ;  but  it  makes  no  difference  in 
practice  whether  the  deformity  is  rickety  or  not. 

Causation  of  the  flat  pelvis.— We  know  noth- 
ing about  the  causes  of  the  flat  pelvis.  It  is  met  with 
more   often   in   slightly-built   under-sized   women,  as 


138  Difficult  Labour. 

might  be  expected,  for  the  causes  that  interfere  with 
the  due  development  of  one  set  of  bones  are  likely  to 
influence  the  development  of  others  also.  But  the  flat 
pelvis  is  sometimes  seen  in  women  of  full  average 
stature,  who  are  otherwise  well  and  strongly  built.  It 
has  been  said  to  be  produced  by  the  practice  of  carry- 
ing weights  on  the  head  in  early  life.  This  may  be  so, 
but  no  evidence  of  it  has  ever  been  brought  forward  ; 
and  the  flat  pelvis  is  often  seen  in  women  who  have 
never  been  in  the  habit  of  carrying  weights.  It  is  com- 
moner in  the  poorer  classes,  because  they  are  the  more 
numerous  ;  but  it  has  never  been  shown  to  be  propor- 
tionately commoner  in  them  than  in  the  rich.  It  has 
been  said — and  I  think  it  probably  true — that  this 
form  of  contracted  pelvis  is  more  common  in  Germany 
than  in  England.  But  no  facts  have  been  adduced  in 
support  of  this,  because  I  know  of  no  English  lying-in 
charity  in  which  systematic  measurement  of  pelves  has 
been  so  thoroughly  carried  out  as  in  the  well-officered 
lying-in  hospitals  of  Germany  ;  nor  do  the  conditions 
under  which  English  practice  is  carried  on  allow  pelves 
to  be  removed  and  thoroughly  examined  after  death  so 
frequently  as  in  some  other  countries.  The  diagnosis 
of  the  slighter  forms  of  contracted  pelvis  is  so  difficult 
that  until  the  pelvis  has  been  measured  after  death  it 
cannot  be  said  to  be  always  beyond  doubt. 

Characters  of  the  flat   pelvis. — In  t\z  flat 

pelvis  the  conjugate  is  the  only  diameter  shortened. 
A  pelvis  in  which  the  true  conjugate  is  three  inches 
and  three  quarters  or  less,  the  other  diameters 
being  normal,  is  a  flat  pelvis.  The  oblique  and 
transverse  measurements  may  even  be  larger  than 
in  the  normal  pelvis.  The  antero-posterior  diameters 
in  the  cavity  and  at  the  outlet  are  shortened,  but 
not  to  the  same  degree  as  the  conjugate.  The  sacrum 
is  pressed  forward  as  a  whole,  and  not  rotated  upon  its 
transverse  axis,  nor  altered  in  shape,  as  it  is  in  the 
rickety  pelvis  (Figs.  57,  58).  The  posterior  sacral 
spines,  owing  to  the  sinking  forward  of  the  sacrum,  are 
often  depressed  slightly  below  the  level  of  the  posterior 


The  Flat  Pelvis.  139 

superior  iliac  spines  ;  and  these  spines  are  also  a  little 
closer  together  than  in  the  normal  pelvis.  The  iliac 
fossae  look  a  little  more  forward  than  in  the  normal 
pelvis,  so  that  the  difference  between  the  interspinous 
and  intercristal  diameter  is  not  so  great  as  in  the 
normal  pelvis.  The  external  conjugate  is,  on  the 
average,  shorter  than  in  the  normal  pelvis.  Its 
shortening  is,  in  a  flat  pelvis,  seldom  enough  to  justify 


Fig.  57. — Sagittal  Section  of  Normal  Pelvis.     (After  Pinard.) 

a  is,  True  conjugate ;  ao,  diagonal  conjugate ;  od,  antero-poBterlor  diameter 
of  outlet. 

any  inference.  The  differences  in  these  external 
measurements  that  exist  between  different  specimens, 
both  cf  normal  and  flat  pelves,  are  so  great  that  no 
inference  can  be  drawn  as  to  flattening  of  the  pelvis 
from  slight  variations  in  these  measurements  or  their 
relations  to  one  another.  The  diagonal  conjugate,  like 
the  true  conjugate,  is  shortened.  The  pelvis  is  sym- 
metrical, and  there  is  no  curvature  of  spine. 

Diagnosis  Of  the  flat  pelvis.  —  Measure 
the  diagonal  conjugate.  This  is  the  principal  point. 
If  the  conjugate  is  not  shortened,  the  pelvis  is  not 


140  Difficult  Labour. 

flattened.  If  the  conjugate  is  shortened,  then  you 
have  to  find  out  that  the  other  diameters  are  approxi- 
mately normal.  Unfortunately,  we  have  no  way  of 
accurately  measuring  during  life  the  transverse  dia- 
meters of  the  true  pelvis,  except  in  cases  of  great 
deformity.  You  may  infer  that  the  pelvis  is  flat 
if  you  find  that,  while  the  diagonal  conjugate  is  only 
four  inches  and  a  quarter  or  less,  the  interspinous  and 
intercristal  diameters  are  eleven  inches  and   a  half 


Fig.  58.— Sagittal  Section  of  Flat  Pelvis.    (After  Pinard.) 

ab,  True  conjugate ;  ao,  diagonal  conjugate;  CD,  antero-posterlor  diameter 
of  outlet.  . 

and  ten  inches  and  a  half  respectively,  or,  more  than 
this :  if,  when  you  try  to  explore  with  your  fingers  in 
the  vagina  the  lateral  walls  of  the  pelvis,  you  find 
you  cannot  easily  do  so,  and  if,  when  you  examine 
the  back,  you  find  the  sacral  spinous  processes  sunk 
below  the  level  of  the  posterior  superior  iliac  spines. 
You  find  also  that  the  patient's  limbs  are  straight, 
and  she  is  not  pigeon-breasted ;  the  pubic  inter- 
articular  cartilage  is  not  thickened ;  the  lines  of 
junction  between  the  sacral  vertebra  are  not 
thickened,  and  the  sacrum  is  concave  from  side  to 
side.     These  latter  points  tell  you  that  the  pelvis  is 


The  Small  Round  Pelvis. 


141 


not  rickety.  If  the  true  conjugate  is  below  three 
inches  and  a  quarter  the  pelvis  is  probably  rickety,  for 
contraction  so  great  as  this  without  rickets  is  very  rare. 

The  generally  contracted  or  small  round 

pelvis. — Those  who  prefer  a  Latin  name  call  this  the 
" pelvis  cequabiliter  justo  minor"  (Fig.  59).  I  prefer 
to  speak  of  it  as  the  small  round  pelvis.  It  is 
characterised  by 
deficient  develop- 
ment of  the  lateral 
masses  of  the  sac- 
rum, and  adjoining 
part  of  the  ilia,  so 
that  the  transverse 
diameters  are  all 
shortened.  The  pel- 
vic bones  are  small, 
so  that  the  conju- 
gate diameter  is 
shortened,  though 
not  so  much  as  the 
transverse  (Fig.  60). 
The  sacral  promon- 
tory is  higher  up, 
so  that  the  diagonal 
conjugate  differs 
more  from  the  true 
conjugate  than  in  the  normal  pelvis  (Fig.  61).  The 
sacrum  is  not  quite  so  much  curved  from  above  down- 
wards, but  it  is  slightly  more  concave  from  side  to 
side.  The  distances  between  the  iliac  crests  and 
anterior  superior  iliac  spines  are  less  than  in  the 
normal  pelvis,  but  the  difference  between  them  is  as 
great,  or  greater.  The  posterior  superior  iliac  spines 
are  a  little  farther  apart,  and  the  posterior  sacral 
spines  often  pi-oject  a  little  above  their  level.  The 
external  conjugate  is  shortened. 

Causation. — We  know  nothing  of  the  causes  of 
the  small  round  pelvis.  It  may  be  found  in  women 
in  every  other  respect  perfectly  developed. 


Fig.  59.— Sagittal  Section  of  Small  Round 
Pelvis.    (After  Pmard.) 

ad,  True   conjugate;  AC,  diagonal  conjugate 
c  d,  antero-posterior  diameter  of  outlet. 


142  Difficult  Labour. 

Diagnosis. — This  is  very  difficult.  It  is  usually 
only  discovered  by  the  difficulty  in  labour.  The 
points  are  these.  The  high  position  of  the  pro- 
montory, and  the  shortening  of  the  conjugate,  and  the 
ease  with  which  the  side  walls  of  the  pelvis  can  be 
felt  with  the  finger.  With  two  fingers  in  the  vagina 
you  can  seldom,  in  a  normal  or  a  flat  pelvis,  easily  feel 
more  than  the  anterior  half  of  the  ilio-pectineal  line. 
If  you  can  easily  trace  the  ilio-pectineal  line  all  the 


A 

Fig.  60.—  Diagram  of  the  Brim  of  the  Small  Round  Pel  via. 

Black  line,  normal  pelvis ;  dotted  line,  small  round  pelvis  ;  b  b,  sacrum ;  cc,  ends 
of  transverse  diameter ;  d  d,  ilio-pectineal  eminences ;  b,  centre  of  sacrum  in 
plane  of  brim  ;  Jl,  symphysis. 

way  round,  the  probability  is  that  the  pelvis  is  of  the 
small  round  kind.  This  statement  cannot  be  laid 
down  as  without  exceptions,  because  the  ease  with 
which  the  ilio-pectineal  line  can  be  traced  depends  not 
only  on  the  size  of  the  pelvis,  but  on  the  length  of  the 
examiner's  fingers,  on  the  amount  of  fat  in  the  pelvic 
floor,  the  projection  of  the  perineum,  and  the  ease 
with  which  it  can  be  pushed  up.  No  positive  conclu- 
sion can  be  drawn  from  slight  diminution  of  the 
external  transverse  measurements ;  but  great  width  of 
them  will  contra-indicate  general  contraction.  To 
these  points  must  be   clinically  added   the  kind  of 


The  Rickety  Pelvis. 


143 


There  is  obstruction,  and  the 


difficulty  in  labour, 
mechanism        is 
not  that  of  the 
flat  pelvis.' 

Rickety 
pelvis. — The 

rickety  pelvis 
may  be  either 
flat,  or  flat  and 
generally  con- 
tracted. The 
only  kind  of  ex- 
treme pelvic  de- 
formity   that    is      Fig.  61.— Diagram  of  the  Cavity  of  the  Small 

,      11   f  ,i  Bound  Pelvis, 

at  ail  irequentiy  AB>True  conjugate;  ao,  diagonal  conjugate;  CD, 
mA+  with  in  TT,n<r-  antero-posterior  diameter  at  outlet;  continuous 
ixioo  wxi-11  xii  -ui±g  linCj  normaj  peivis ;  dotted  line,  contracted  pelvis 

lish    practice    is 

the  small  rickety  pelvis  (Fig.  62).  The  combination 
of  flattening  and  general  contraction  of  the   pelvis 

"without  rickets 


is  rare. 

Signs  of 
rickets.— The 

signs  that  indi- 
cate that  the 
deformity  is 
rickety  are  three: 
(1)  Stunting  in 
growth;  (2)  evi- 
dence of  soften- 
ing of  the  bones ; 
(3)  thickening 
of  epiphyses. 

(1)  Rickety 
subjects  are 
short  -  legged, 
therefore  they 
are  generally  be  ■ 


Fig.  62. 


-Sagittal  Section  of  Flat  Rickety  Pelvis. 
{After  Pinard.) 

ab.  True  conjugate;  Ac,  diagonal  conjugate;  cd, 
autero-posterior  diameter  of  outlet. 


low  middle  stature.    The  shortness  of  the  legs  is  often 
increased  by  bending  of  the  leg  bones;  and  the  stature 


144  Difficult  Labour. 

further  diminished  by  curvature  of  the  spine.  The 
pelvic  bones  are  stunted  in  growth,  as  well  as 
distorted,  and  therefore  the  wings  of  the  ilia  are 
smaller,  and  the  pelvis  is  shallow  from  above 
downwards. 

(2)  The  bones  during  growth  were  soft,  and  have 
yielded  to  pressure  and  pulling.  Hence,  besides  the 
curving  of  the  long  bones,  of  the  ribs,  and  of  the  spine, 


A 

Fig.  68.— Diagram  of  Rickety  Flat  Pelvis. 

b  b.  Sacrum  ;  K,  centre  of  sacrum  at  lerel  of  brim ;  cc,  transverse  diameters; 
d  d,  ilio-pectineal  eminences ;  a,  pubes  ;  continuous  line,  normal  pelvis, 
dotted  line,  contracted  pelvis* 


the  pelvic  bones  are  distorted.  The  sacrum  is  not 
only  sunk  forward  as  in  the  flat  pelvis,  but  it  is  bent 
(Fig.  63).  The  upper  part  of  it  is  pressed  down  by  the 
body  weight,  while  the  lower  part  is  held  up  by  the  liga- 
ments which  run  between  it  and  the  ossa  innominata. 
Hence  there  is  a  sharper  curve  of  the  sacrum  at  its 
lower  part  fjrom  above  downwards  (Fig.  62).  The  pres- 
sure of  the  body  weight  on  the  sacrum  falls  on  the  bodies 
of  its  component  vertebrae,  while  the.  ligaments  which 
sustain  it  are  inserted  chiefly  into  its  lateral  masses. 
Hence,  when  the  sacrum  yields  to  the  pressure,  the 


The  Rickety  Pelvis. 


145 


Fig.  64.— Rickety  Flat  Pelvis. 
a  b.  True  conjugate  ;   a  c,  diagonal  conjugate ;   o  d, 
antero-posterior  diameter  at  outlet ;    black  line, 
normal  pelvis;  dotted  line,  contracted  pelvis. 


bodies  sink    forward,    so    that    the    anterior    surface 
becomes    flat  or  A 

even  convex 

from  side  to  side, 
instead  of  con- 
cave, and  the 
upper  part  of  the 
sacrum  straigh- 
ter  from  above 
downwards  (Fig. 
64:).  The  bones 
yield  to  the  up- 
ward pressure 
of  the  femora, 
which  press  the 
acetabula  verti- 
cally upwards, 
and  so  widen  the  pelvis.  The  bones  being  small,  not 
only  is  the  conjugate  shortened,  but  the  transverse 
dimensions  are  seldom  larger  than  normal,  and  some- 
times smaller, 
notwithstand  i  ng 
the  widening 
(Fig.  66).  The 
sacrum  is  nar- 
row, from  imper- 
fect development 
of  its  lateral 
masses.  The  pos- 
terior superior 
iliac  spines  are 
therefore  closer 
together.  The 
bones  also  yield 
to  the  pull  of 
muscles.  The 
glutei  pull  the 
wings  of  the  ilia 
outwards,  backwards  and  downwards,  and  hence  the 
wings  of  the  ilia,    besides   being   smaller,  are   more 

k— 36 


Fig.  65.— Diagram  of  Brim  of  Small  Flat  Rickety 
Pelvis. 

BB,  Sacrum  ;  B,  centre  of  sacrum  in  plane  of  brim  : 
C  0,  transverse  diameter ;  d  d,  ilio-pectineal 
eminences;  a,  symphysis  pubis;  continuous  line, 
normal  pelvis;  dotted  line,  contracted  pelvis. 


146 


Difficult  Labour. 


inclined  than  normal  to  the  horizon,  and  more  open 
anteriorly,  while  their  fossse  look  more  upwards  and 
forwards,  and  less  inwards,  than  they  should  do. 
The  iliac  crests  are  short,  and  do  not  curve  in- 
wards at  their 
anterior  ends  as 
much  as  in 
normal  pelves, 
and  often  do  not 
curve  inwards 
at  all,  so  that 
the  measure- 
ment between 
the  anterior 
superior  iliac 
spines  is  nearly 

Fig.  ee.-Diagram^PeMc^Cavity  in  Small  Flat   or  quite  ag  great 

Continuous  line,  norma]  pelvis;  dotted  line,  contracted  ^  "lie  Oiiameter 
pelvis:  A u,  true  conjugate;  a 0, diagonal  conjugate;  V1otw»f»n  onv 
DO,  antero-posterior  diameter  of  outlet.  uoi/wcoii       aiijr 

part  of  the 
crests.  The  obturator  muscles  pull  outwards  the 
ischia,  and  hence  the  pubic  arch  is  widened  and  the 
ischia  are  everted. 

(3)  There  is  thickening  of  the  epiphyses.  The 
pubic  symphysis  is  thickened,  so  that  where  the  two 
pubic  bones  meet  you  have  a  swelling  instead  of  a 
depression.  The  lines  of  junction  between  the  sacral 
vertebrae  are  also  thickened. 

The  history  is  of  no  value  in  the  diagnosis  of 
past  rickets.  You  may  be  told  that  the  patient  was 
late  in  walking.  But  often  the  patient  will  know 
nothing  about  this,  or  may  tell  you  that  she  walked 
at  the  proper  time.  And  even  if  you  can  find  out 
that  the  patient  was  rickety  in  childhood,  the  effects 
of  rickets  on  the  pelvis  are  so  various  (depending  on 
the  duration  of  the  disease  and  other  influences),  that 
you  have  not  gained  information  of  much  value  for 
the  management  of  labour. 

Rickets  may  be  present  without  stunting  of  growth. 
Then  we    have    the    flat    rickety  pelvis    (Fig.     63). 


The  Rickety  Pelvis.  147 

The  shape  of  this  pelvis  is  almost  the  same  as  that 
of  the  flat  pelvis,  but  the  deformity  is  greater.  There 
is  more  inclination  of  the  sacrum,  owing  to  lordosis 
of  the  spine.  The  transverse  diameter  may  be  slightly 
increased,  from  the  femora  pressing  the  acetabula  up 
and  out.  Apart  from  the  degree  of  the  deformity, 
the  rickety  flat  pelvis  is  distinguished  from  the  non- 
rickety  flat  pelvis  only  by  the  rickety  changes  in 
the  bones,  the  thickening  of  the  epiphyses,  the 
diminished  concavity  or  even  convexity  of  the  sa- 
crum from  side  to  side.  Flattening  of  the  pelvis  of  a 
high  degree  is  usually  rickety. 


148 


CHAPTER  XIII 

THE    RESULTS   OF   CONTRACTED    PELVIS. 

In  this  chapter  I  propose  to  state  broadly  the  effects 
of  contraction  of  the  pelvis,  taking  all  varieties 
together.  In  a  subsequent  chapter  I  shall  describe 
more  in  detail  the  mechanism  of  the  common  kinds. 
Although  these  effects  may  result  from  any  kind  of 
pelvic  contraction,  yet  our  knowledge  of  then;  and  of 
the  mechanism  is  derived  from  observation  of  the 
common  kinds  ;  and,  therefore,  a  description  of  these 
effects  comes  appropriately  here.* 

Retroversion   and    incarceration    of    the 

gravid  Uterus. — The  flat  pelvis  brings  with  it  an 
increased  liability  to  incarceration  of  the  retroverted 
gravid  uterus.  If  the  body  of  the  uterus  falls  down 
into  the  hollow  of  the  sacrum,  the  projecting  pro- 
montory of  a  flat  pelvis  will  much  more  oppose  its 
rising  up  than  a  sacrum  whose  promontory  occupies  the 
natural  position.  Hence  in  patients  with  flat  pelvis, 
retroversion  with  incarceration  of  the  gravid  uterus, 
with  the  troubles  resulting  therefrom — retention  of 
urine  and  its  consequences — is  sometimes  seen  repeated 
in  pregnancy  after  pregnancy. 

Abnormal  mobility  of  uterus  and  child. — 
When  the  pelvis  and  child  are  each  of  average  size,  the 
lower  end  of  the  foetal  ovoid — which  is  usually  the 
head — sinks  during  the  last  weeks  of  pregnancy  into  the 
pelvis.  When  this  has  happened,  the  mobility  of 
the  child  is  restricted ;  for  if  the  head  is  engaged  in 
the  brim,  the  movements  of  the  child  must  be  very 

*  Much  of  the  knowledge  contained  in  this  and  the  following 
chapters  is  derived  from  the  great  work  of  Litzmann — Die  Geburt 
bci  cngem  Bcckcn.  Many  of  his  observations  I  have  confirmed  by 
my  own,  and  I  therefore  accept  those  which  I  have  not  been  able 
to  test. 


Results  of  Contracted  Pelvis.  149 

vigorous  indeed  to  get  it  out.  The  fixation  of  the  pre- 
senting end  of  the  child  in  the  brim  restricts  not  only 
the  movements  of  the  child,  but  also  the  ease  with 
which  external  agencies — such  as  coughing,  straining, 
the  pressure  of  garments,  and  position — can  move  the 
uterus.  When  the  pelvis  is  contracted  at  the  brim, 
the  head  cannot  easily  enter  the  brim,  and  therefore  does 
not  become  fixed  in  the  pelvis.  Hence  there  is  greater 
freedom  of  movement  of  the  child  up  to  the  end  of 
pregnancy,  and  greater  mobility  of  the  uterus,  making 
lateral  obliquity  and  pendulous  belly  more  frequent  in 
pregnancy  with  contracted  pelvis  than  with  normal 
pelvis. 

Pendulous  belly. — Some  forms  of  contracted 
pelvis  result  from  influences  affecting  the  growth  of 
the  whole  skeleton,  producing  shortness  of  stature 
and  even  curvature  of  the  spine,  and  thus  lessening 
the  space  within  the  abdomen  ;  and  this  want  of  room, 
added  to  the  increased  mobility  of  the  uterus,  leads 
often  to  the  displacement  of  the  uterus  forwards,  known 
as  pendulous  belly  (Fig.  67).  This  displacement  of 
the  uterus  is  more  apt  to  occur  in  later  pregnancies 
than  in  earlier,  because  in  the  later  previous  distension 
has  stretched  the  muscular  wall  of  the  belly  and  made 
it  looser  and  weaker. 

Malpresentations. — The  greater  mobility  of  the 
foetus,  and  failure  of  the  head  to  get  engaged  in  the 
brim,  make  malpresentations  very  apt  to  occur  in 
contracted  pelvis.  Thus  prolapse  of  the  cord,  and  of 
the  hand,  have  been  estimated  to  occur  from  four  to 
six  times  oftener,  and  face,  shoulder,  and  pelvic  pre- 
sentations occur  two  or  three  times  oftener  with 
contracted  than  with  normal  pelvis.  When  the 
pelvic  end  presents,  foot  presentation  is  with  flat 
pelvis  more  common  than  breech  presentation,  while 
with  normal  pelvis  the  reverse  is  the  case. 

Frequent  change  of  presentation. — From  the 

greater  mobility  of  the  child  result  not  only  abnormal 
presentations,  but  more  frequent  changes  in  the  part 
which  presents  than  is  usual  with  normal  pelvis.    The 


IS© 


Difficult  Labour. 


presenting  part  often  changes  during  pregnancy.  The 
occurrence  of  frequent  change  in  the  presenting  part 
is  favoured  by  weakness  of  the  uterus,  and  weakness 
and  looseness  of  the  abdominal  walls.  In  first  preg- 
nancies the  firm  contractions  of  the  uterus,  and  the 
resistance  of  the  abdominal  walls,  help  to  keep  in 
relation  with  the  pelvic  brim  a  part  that   has  once 


Fig.  67.— Showing  what  is  meant  by  "Pendulous  Belly."  (After  R.  Barnes.) 

ae,  Normal  axis  of  uterus  and  child;  bf,  axis  of  uterus  and  child  with 
pendulous  belly ;  s, symphysis  pubis;  od,  line  indicating  path  of  foetal  head 
round  pubes. 

become  partly  engaged  in  it.  The  uterus  and  abdo- 
minal walls  are  less  powerful  in  later* pregnancies,  and 
hence  abnormal  presentations  and  frequent  changes  in 
the  presenting  part  are  more  common  in  later  preg- 
nancies than  in  the  first.  A  very  little  mechanical 
obstruction,  easily  overcome  by  the  pains  when  labour 
has  begun,  will  prevent  the  head  from  engaging  in  the 
brim  during  pregnancy. 

Effect  on  the  pains. — Contraction  of  the  pelvis 
does  not  bring  with  it  any  special  tendency  either  to 
very  strong  or  very  weak  pains,     The  strength  or 


Results  of  Contracted  Pelvis.  151 

weakness,  quickness  or  slowness,  of  uterine  action 
depends  upon  conditions  of  the  nerves  and  muscular 
fibre  of  the  uterus,  which  we  do  not  understand.  But 
the  ill  effects  which  follow  either  excessive  strength 
and  frequency,  or  weakness  and  infrequency,  of  pains 
are  much  greater  in  contracted  pelvis  than  with  a 
normal  pelvis. 

How  to  judge  as  to  uterine  action.— It  is  not 

possible  to  judge  of  the  strength  of  pains,  without 
watching  the  patient  for  some  time.  One  pain  is  not 
exactly  like  those  that  precede  and  follow  it ;  weak 
pains  alternate  with  strong  ones.  We  have  no  means 
that  can  be  applied  in  practice  of  judging  as  to  the 
absolute  strength  of  pains.  The  only  real  practical 
test  of  the  effectiveness  of  pains  is  the  amount  of 
advance  in  the  presenting  part  that  they  produce. 

Effects  Of  weak  pains.— The  head  may  be  of 
such  size  that  it  cannot  easily  enter  the  brim,  but  can 
be  brought  through  it  by  a  little  moulding.  If  the 
pains  are  strong,  the  head  will  be  driven  into  the 
brim,  and  the  child  will  be  born  naturally.  If 
the  pains  are  weak,  the  head  will  not  be  driven  into 
the  brim.  After  the  membranes  have  ruptured,  the 
liquor  amnii  drains  away ;  the  uterus  becomes  con- 
tracted round  the  child,  and  the  cord  is  pressed  on, 
and  the  child  may  die.  The  labour  is  so  long  that 
the  mother  suffers  from  exhaustion. 

Effect  of  very  strong  pains. — If  the  pains  are 

excessively  violent,  and  the  degree  of  disproportion 
between  the  head  and  the  pelvis  is  so  great  that  the 
head  cannot  enter  the  pelvis,  then  retraction  of  the 
body  of  the  uterus,  and  stretching  and  thinning  of 
the  cervix  and  lower  segment  of  the  uterus,  go  on 
very  fast,  and  danger  of  rupture  of  the  uterus  comes 
on  early. 

Indirect  effects  on  the  pains. — Although  there 

is  no  direct  influence  exerted  on  the  pains  by  pelvic 
contraction,  yet  by  the  obstruction  to  delivery  it 
offers,  contraction  of  the  pelvis  comes  to  affect 
the  pains  in  the  course  of  labour.     The  presence  of 


15a  Difficult  Labour. 

resistance  stimulates  the  uterus  to  increased  action. 
Prolonged  muscular  action  exhausts  nerve  force,  and 
therefore  after  pains  have  continued  long,  secondary 
uterine  inertia  may  come  on.  If  this  happen,  and  the 
case  is  let  alone,  the  mother  will  sleep,  and  then  the 
pains  will  recommence,  and  the  stimulus  of  resistance 
will  make  them  come  on  stronger  and  faster  than 
before.  It  has  been  said  that  in  the  small  round  pelvis 
paralysis  of  the  uterus  is  apt  to  take  place  from  pres- 
sure on  the  sacral  nerves,  but  observation  has  not 
shown  this  to  happen  so  often  as  by  the  theory  it 
ought  to  do. 

Delay  in  the  first  stage  of  labour.  (1)  Before 
rupture  of  the  membranes. — In  contracted  pelvis, 
owing  to  the  head  not  coming  down  into  the  pelvis, 
it  does  not  fill  the  circle  of  the  os  uteri,  and  therefore 
does  not  dam  off  the  portion  of  the  liquor  amnii  which 
is  in  front  of  it  from  the  bulk  of  the  waters  behind. 
Hence  the  presenting  portion  of  the  bag  of  membranes 
is  exposed  to  the  full  intra-uterine  pressure.  In  con- 
sequence the  membranes  bulge  much  more  than  in 
normal  labour,  forming,  when  the  os  is  small,  a 
process  like  the  finger  of  a  glove,  and  they  are  likely, 
from  the  increased  pressure  on  them,  to  break  early. 
Then  follow  all  the  bad  effects  of  premature  rupture 
of  membranes. 

(2)  After  rupture  of  the  membranes. — Supposing, 
however,  that  the  membranes  are  strong,  and  the 
pains  not  too  violent,  and  that  therefore  the  mem- 
branes remain  entire  until  the  bag  of  waters  has  ful- 
filled its  function  of  stretching  open  the  os  uteri,  and 
that  at  this  time  the  membranes  give  way  or  are 
ruptured,  the  head  cannot  come  down  into  the  cervix, 
and  so  the  lips  of  the  os  fall  together  again,  hanging 
down  like  a  thick  soft  fringe  into  the  vagina.  As  the 
head  does  not  fill  the  cervical  canal,  it  does  not 
prevent  the  flowing  away  of  the  liquor  amnii.  In  a 
normal  labour,  while  a  good  deal  of  liquor  amnii  comes 
away  when  the  membranes  rupture,  yet  the  head  soon 
comes  down  into  the  os  uteri,  fills  it  up,  and  stops 


Injuries  from  Contracted  Pelvis.      153 

further  escape  of  liquor  amnii,  so  that  often  a  good 
deal  is  retained  until  after  the  child  is  born,  when  it 
comes  away  in  a  gush.  Between  the  pains  the  fluid 
drains  away  gradually,  but  enough  is  usually  retained 
to  prevent  injurious  pressure  on  the  uterus  or  on  the 
child. 

In  a  conti-acted  pelvis  the  head  does  not  fill  the 
os,  the  uterus  is  comparatively  soon  emptied  of  liquor 
amnii,  and  comes  to  press  injuriously  on  the  foetus, 
and  to  be  itself  exposed  to  dangerous  pressure.  The 
uterine  pressure  is  exerted  more  directly  and  more 
powerfully  on  the  foetus.  If  the  disproportion  is  not 
very  great,  the  uterus  may  drive  the  foetal  head  through 
the  brim,  and  then  it  will  come  into  the  cervical  canal, 
which  will  quickly  yield  and  be  stretched  open  by  the 
head.  But  if  it  does  not  enter  the  pelvis,  the  cervix 
uteri  is  nipped  between  the  head  and  the  brim  of  the 
pelvis,  and  from  this  injury  follows. 

Injuries  to  the  cervix  and  vagina  in  con- 
tracted pelvis. — Such  nipping  as  has  been  described 
hinders  the  return  of  blood  from  the  part  below  the 
seat  of  pressure.  Hence  the  cervix  below  the  head 
gets  swollen  and  cedematous.  This  is  especially 
marked  if  the  cervix  has  been  in  former  labours  torn 
into  lobes.  I  have  been  called  to  a  case  in  which 
one  lobe  of  the  cervix  uteri,  thus  caught  between 
the  head  and  the  pelvic  brim,  was  so  swollen  that  the 
medical  man  took  it  for  a  tumour.  Such  great  swel- 
ling is  an  indication  of  the  need  for  delivery.  If  the 
patient  be  soon  delivered,  the  swelling  quickly  sub- 
sides afterwards.  If  the  patient  be  not  quickly 
delivered,  there  will  be  haemorrhage  into  the  tissues, 
and  finally  such  destruction  of  tissue  as  to  lead  to 
sloughing.  This  sloughing  affects  first  the  tissues 
nearest  the  foetus.  In  the  worst  cases  the  whole 
thickness  of  the  tissues  nipped  between  the  head  and 
the  pelvic  brim  is  destroyed :  part  of  uterus  or  vagina, 
or  both,  and  base  of  bladder ;  and  thus  a  vesical  fistula 
is  produced.  If  the  cervix  is  held  down  till  the  tissues 
are  killed,  a  utero-vesical  fistula  is  formed.     Usually, 


154  Difficult  Labour. 

the  prolonged  action  of  the  uterus  pulls  up  the  cervix, 
leaving  the  most  continuous  and  powerful  pressure  to 
be  exerted  on  the  vagina ;  vesico-vaginal  fistula  is 
therefore  the  more  common  result. 

The  opening  in  the  bladder  is  usually  formed  some 
days  after  delivery,  when  the  mass  of  tissue  killed  by 
the  pressure  has  been  separated  by  suppuration  round 
it,  or  has  softened  and  given  way  to  the  pressure  of 
the  urine. 

Such  injuries  as  these  are  usually  produced  by  the 
mutual  pressure  of  the  foetal  head  and  the  pelvic 
brim.  The  breech  is  too  soft  to  do  much  damage ;  so 
is  the  shoulder.  The  forms  of  pelvic  deformity  that 
contract  the  outlet  might,  if  they  were  given  oppor- 
tunity, produce  the  same  effect ;  but  they  are  rare, 
and  the  delay  and  its  cause  are  comparatively  easy  of 
diagnosis,  and  therefore  we  seldom  see  such  injury 
from  detention  in  the  pelvic  cavity.  At  first  the  most 
severe  pressure  is  exerted  on  the  symphysis,  and  there- 
fore the  part  of  the  genital  passage  in  front  suffers 
most.  The  uterus  opposite  the  promontory  may  also 
be  perforated.  But  while  the  slough  in  front  opens 
an  important  viscus,  that  behind  only  opens  a  sac  of 
peritoneum  which  usually  contains  nothing ;  and  if 
the  patient  be  kept  clean,  it  is  soon  closed  by  adhesive 
inflammation. 

Effects  on  the  child's  head.— These  are  im- 
portant and  interesting,  for  they  show  where  the 
head  has  been  most  squeezed  in  its  passage  through 
the  pelvis.  In  a  difficult  case  we  may,  as  it  were, 
read  the  history  of  the  labour  written  on  the  child's 
head. 

The  effects  are  the  following  : — 

1.  Swelling  of  the  subcutaneous  tissue  below  the 
place  where  the  head  is  squeezed. 

2.  Redness,  bruising,  and  excoriation  of  the  skin 
at  the  point  of  pressure. 

3.  Deformity  of  the  head. 

4.  Dinting  and  fracture  of  the  cranial  bones. 

5.  Haemorrhage  into  or  on  to  the  brain. 


Effects  on  the  Child's  Head.         155 
The  caput  succedaneum. — The  return  of  blood 

from  the  presenting  part,  which  after  the  rupture  of  the 
membranes  is  pressed  into  the  cervix  uteri,  is  hindered 
in  a  normal  labour  by  the  pressure  of  the  circle  of  the 
os.  Hence  this  part  becomes  swollen,  from  oedema 
and  ecchymosis.  The  longer  the  first  stage  of  labour 
lasts,  the  greater  will  be  the  oedema  and  ecchymosis. 
The  cedematous  part  of  the  scalp  is  called  the  caput 
succedaneum.  After  full  dilatation  of  the  os,  the 
head,  if  the  pelvis  be  small,  is  pressed  on  by  the 
walls  of  the  pelvis,  which  produces  the  same  effect 
as  the  os  uteri  did ;  and  the  caput  succedaneum  gets 
still  larger.  The  longer  the  labour,  and  the  more 
tightly  the  head  is  jammed  all  round  into  the  pelvic 
cavity,  the  greater  the  caput  succedaneum.  From  the 
movement  of  the  head  there  is  a  little  alteration  in 
the  situation  of  the  centre  of  the  caput  succedaneum 
during  labour.  The  most  marked  examples  of  caput 
succedaneum  are  therefore  seen  in  labour  with  very 
large  children,  and  with  a  small  round  pelvis,  because 
in  these  cases  the  head  is  pressed  on  all  round.  In 
the  flat  pelvis,  on  the  other  hand,  the  head  is  squeezed 
in  the  diameter  which  lies  in  the  contracted  conjugate, 
and  is  pressed  on  comparatively  little  at  other  parts. 
Hence  a  larger  caput  succedaneum  than  that  formed 
in  the  first  stage  of  labour  is  not  often  seen  with  a 
flat  pelvis. 

Occasionally  we  may  see  two  distinct  swellings, 
one  produced  by  the  pressure  of  the  os  uteri,  one  by 
that  of  the  pelvic  bones.  Sometimes  by  the  time  the 
child  is  born  the  first  caput  succedaneum,  that  formed 
by  the  os  uteri,  has  been  absorbed,  and  only  some 
venous  congestion  and  wrinkling  of  that  part  of  the 
scalp  remains  to  show  where  it  was. 

2.  Pressure  marks  on  the  skin. — These  are 
most  often  seen  where  the  side  of  the  head  has 
scraped  past  the  sacral  promontory,  because  this  is 
the  most  projecting  part  of  the  brim,  and,  indeed,  of 
any  part  of  the  pelvic  canal.  In  a  flat  pelvis  the 
head  lies   so  that  the  parietal  bone    is   opposite  the 


i56 


Difficult  Labour. 


Fig.  68. — Showing  Pressure  Marks  on  Head 
after  a  Labour  with  Flat  Pelvis.  {After 
Fritsch.) 


promontory,  and 
therefore  these 
marks  are  gener- 
ally over  the  pa- 
rietal bone  (Fig. 
68).  If  the  head 
is  not  lying  trans- 
versely, the  frontal 
or  occipital  bones 
may  be  opposite 
the  promontory 
and  the  skin  over 
them  may  receive 
pressure  marks 
(Fig.  69).  The 
slightest  of  these 
marks  consists  in 
redness,  either  in 
a  round  or  oval 
spot,  or  in  a  stripe, 

according  to  the  extent  to  which  the  head  was  altered 

in  shape  by  squeez- 
ing.    If  the  head  is 

hard,    and   keeps    its 

shape,   the   effect   on 

the   skin   is   confined 

to    a     spot    marking 

the  end  of  the  largest 

diameter  which  passed 

the  brim.  If  the  head 

is    soft,    so    that    it 

moulds,  and  its  sides 

become         flattened, 

then,    as     it     moves 

along  the  promontory, 

a   red   stripe   is    left 

along  the  path  of  the 

promontory.        Hard 

and         long-continued      Fig.  69.— Showing     Pressure  Marks  on 
j  Head    after    a  Labour   with    Small 

pressure  produces  not  Bound  Pelvis.    (After  Kiistner.) 


Deformity  of  Head.  157 

merely  redness,  but  ecchymosis.  In  veiy  protracted 
labours  the  skin  may  be  killed  where  it  is  pressed  on; 
it  looks  not  red  or  blue,  but  white,  surrounded  with  a 
red  or  blue  margin  of  congestion  or  ecchymosis;  and  the 
white  part,  if  the  child  survives,  sloughs.  Such  damage 
results  not  necessarily  from  great  pressure,  but  from 
long  pressure.  Fatal  pyaemia,  having  its  origin  in 
such  sloughing,  has  been  known;  but  by  antiseptic 
precautions  this  ought  to  be  prevented.  When  the 
nipping  of  the  head  is  extensive,  the  parts  not  pressed 
on  may  become  slightly  ©edematous,  and  this  oedema 
is  most  evident  in  the  eyelids,  because  here  the  con- 
nective tissue  is  looser,  and  the  appearance  more 
conspicuous. 

3.  Deformity  of  the  head.— The  head  is 
squeezed  so  that  those  diameters  that  pass  through 
the  contracted  parts  of  the  pelvis  are  made  smaller. 
The  results  of  this  moulding  demand  attention. 

Over-riding  of  the  sutures. — First,  the  bones  at  the 
sutures  over-ride  one  another.  This  is  very  common, 
and  happens  in  normal  labour  merely  from  the  resist- 
ance of  the  soft  parts  to  being  stretched  open ;  but 
when  the  resistance  is  from  deformity  of  the  bones, 
over-riding  takes  place  to  a  greater  degree.  As 
from  the  projection  of  the  promontory  the  posterior- 
lying  parietal  bone  is  the  more  pressed  on,  the  edge 
of  the  posterior  parietal  bone  is  pushed  underneath 
the  anterior.  In  exceptional  cases  the  same  thing 
may  occur  at  the  frontal  suture  ;  and  the  edge 
of  the  squamous  part  of  the  temporal  bone  may  be 
pushed  under  the  parietal  bone.  These  are  the  sutures 
at  which  the  bones  over-ride  one  another  in  flat  pelves. 
If  the  pelvis  is  contracted  in  other  diameters  than  the 
conjugate,  the  chief  pressure  may  be  on  the  frontal 
and  occipital  bones,  and  the  edges  of  these  bones 
may  be  forced  under  the  parietal  bones  at  the  coronal 
and  lambdoid  sutures  respectively.  After  delivery  the 
difference  in  the  level  of  the  bones  at  the  sutures 
gradually  becomes  effaced,  and  is  usually  gone  within 
twenty-four  or  forty-eight  hours  after  delivery.     The 


158  Difficult  Labour. 

kind  of  over-riding  shows  where  the  head  was  most 
pressed  on,  and  therefore  gives  useful  information 
about  the  situation  of  the  chief  hindrance  to  its 
progress.  Great  over-riding  brings  risk  of  laceration 
of  veins  and  sinuses,  and  intra-cranial  haemorrhage  ; 
and  intra-cranial  haemorrhage  is  one  of  the  chief  causes 
of  death  of  the  child  during  delivery. 

Lateral  asymmetry.-r-There  is  another  kind  of 
displacement  at  the  sutures  which  occurs  in  labour 
with  contracted  pelvis  :  that  is,  a  displacement  in  the 
sagittal  plane  of  the  right  and  left  halves  of  the 
cranium.  It  results  from  the  projection  of,  and  the 
greater  resistance  offered  by,  the  promontory.  Thus 
in  a  small  round  pelvis,  in  which  the  head  enters 
extremely  flexed,  with  the  occiput  in  advance,  the 
resistance  of  the  promontory  will,  if  the  labour  be 
difficult,  press  forwards  the  half  of  the  head  which  lay 
posterior  in  front  of  the  half  which  lay  anterior.  In 
the  flat  pelvis,  on  the  other  hand,  in  which  the  head 
enters  with  the  forehead  low  down,  and  the  bi- 
temporal diameter  in  the  conjugate,  the  parietal 
eminence,  and  therefore  the  half  of  the  cranium 
which  lay  posterior,  will  be  pressed  backwards.  This 
description  holds  good  of  most  cases,  but  there  are 
exceptions.  An  asymmetrical  shape  of  the  head  is 
thus  produced. 

Flattening  of  one  side  of  the  skull. — In  a  labour 
with  flat  pelvis  the  side  of  the  cranial  vault,  which 
lies  behind,  becomes  flattened,  and  the  side  which  is 
in  front  becomes  more  arched.  As  the  parietal  bone 
is  the  one  most  pressed  against  the  promontory,  the 
flattening  is  most  marked  in  this  bone.  Owing  to 
this  flattening  the  distance  between  one  parietal 
eminence  and  the  opposite  ear  may  be  as  much  as 
half  an  inch  greater  than  the  corresponding  measure- 
ment on  the  opposite  side.  The  arching  is  due  to  an 
increase  in  the  curve  of  the  parietal  bone,  as  if  its 
sagittal  and  its  temporal  borders  had  been  pressed 
together.  In  the  small  round  pelvis  the  flattening 
chiefly  affects  the  frontal    bone.      No  harm   to  the 


Dinting  of  the  Bones.  159 

child  results  from  this  flattening  of  the  foetal  head 
per  se ;  but  it  is  often  accompanied  with  intracranial 
haemorrhages.  If  the  child  live,  its  head  will 
gradually  regain  its  natural  shape. 

4.  Dinting  of  the  bones. — This  is  not  a  common 
effect,  but  it  is  important,  because  these  dints,  even 
more  clearly  than  the  bruising  of  the  skin  of  the  head, 
show  where  the  head  has  fitted  tightly  in  its  passage 
through  the  pelvis.  The  dints  are  almost  always 
made  by  the  promontory  of  the  sacrum.  The  most 
common  kind  is  a  groove  on  that  parietal  bone  which 
lay  behind,  running  parallel  with  its  anterior  border. 
The  formation  of  a  groove  like  this  depends  more 
upon  softness  of  the  bones  than  upon  length  of  the 
labour.  It  shows  us  how  the  head  has  come  through 
the  brim,  but  does  not  tell  us  much  as  to  the  amount 
of  mechanical  difficulty.  The  child  is  not  any  the 
worse  for  the  groove  in  its  skull,  which  gradually 
disappears  as  the  child  grows.  There  is  a  less 
common  mark,  viz.  a  deep  spoon-shaped  dint.  The 
usual  place  for  this  is  on  the  parietal  bone,  in  front  of 
the  protuberance.  It  also  occurs  chiefly  when  the  foetal 
head  is  soft.  A  deep  dint  is  often  accompanied  by 
haemorrhage  between  the  pericranium  and  the  bone. 
If  the  child  survive,  the  dint  is  slowly  effaced.  A 
dint  like  this  may  be  produced  by  a  forceps  blade,  if 
the  pull  is  violent  and  the  head  not  well  seized,  but  held 
between  the  tips  of  the  blades  instead  of  between  the 
fenestrae.  A  dint  may  be  produced  by  the  pro- 
montory while  the  head  is  being  dragged  through 
with  forceps,  and  such  a  dint  may  be  in  some  other 
part  of  the  head  than  that  which  has  been  mentioned 
as  the  usual  one,  the  precise  spot  depending  upon  the 
position  of  the  head  when  it  was  seized  with  the 
forceps.  Lastly,  the  pressure  may  do  more  than  dint 
the  parietal  bone  :  it  may  fracture  it.     This  is  rare. 

Injuries  in  head  last  delivery. — When  the  after- 
coming  head  is  dragged  through  a  contracted  brim  base 
first  it  may  be  dinted  as  when  driven  through  head  first 
(Fig.  70).     But  there  are  certain  other   injuries  to 


i6o 


Difficult  Labour. 


which  the  head  is  not  liable  when  it  comes  in  advance. 

The  squamous  part  of  the  temporal  bone  may  be  driven 

underneath  the  pa- 
rietal bone.  The 
squamous  suture  or 
the  lambdoid  suture 
may  be  torn  through. 
The  dinting  of  the 
parietal  bone  is  mostly 
on  its  eminence.  The 
two  parietal  bones  are 
pressed  together,  so 
that  they  meet  at  a 
more  acute  angle  than 
in  the  natural  shape 
of  the  head  (Fig.  71). 
(This  may  happen  if 
the  head  comes  first, 
and,  which  in  the  flat 
pelvis  is  rare,  enters 
without  any  obliquity 

at  all.)     The  basilar  portion  of  the  occipital  bone  may 

be  torn  from  the  squamous  portion. 

5.  Haemorrhage  into,  or  on  to,  the  brain.— 

This  has  already  been  referred 
to,  and  its  production,  ex- 
plained. It  is  the  common 
cause  of  stillbirth  after  diffi- 
cult or  instrumental  delivery. 
The  haemorrhage  is  usually  into 
the  meninges  at  the  base  of 
the  brain  ;  less  often  over  the 
hemispheres,  or  into  the  ven- 
tricles :  very  rarely  into  the 
brain  substance.* 

Dangers  to  the  mother. 

—  Contracted  pelvis  brings 
with  it  a  greater  risk  of  ma- 
ternal illness  and  death  after 


Fig.  70.— Showing  Mark  made  by  Promon- 
tory in  Delivery  of  the  after-coming 
Head.    (After  Kustner.) 


71. — Showing  Change  in 
Shape  of  Head  produced 
by  Traction  with  Base  in 
advance.  (After  Galabin.) 


*  See  Spencer,  Obst.  Trans.,  vol.  xxxiiL 


Dangers  of  Contracted  Pelvis.         161 

labour.  The  great  cause  of  illness  and  death  is 
wrong  diagnosis,  or  rather  diagnosis  not  made  till  too 
late,  that  is,  not  before  damage  has  been  done  by 
protracted  labour,  or  by  futile  efforts  at  dragging 
the  child's  head  through  a  pelvis  which  could  not 
possibly  admit  it.  The  use  of  antiseptics  has  made 
obstetric  operations,  like  all  surgical  operations,  far 
less  dangerous  than  they  used  to  be ;  but  it  does  not 
remove  all  danger  in  contracted  pelvis.  The  essen- 
tial thing  is  to  recognise  the  shape  of  the  pelvis 
early,  so  that  the  patient  may  be  delivered  in  the 
way  proper  for  the  case.  Hence  statistics  show, 
what  at  first  is  surprising,  that  in  lying-in  hospitals 
and  maternity  charities  better  results  have  been 
obtained  in  cases  where  the  pelvic  contraction  has 
been  considerable  than  in  those  where  it  has  been 
slight.  This  is  because  the  bad  cases  are  easily 
diagnosed,  and  the  proper  treatment  is  used  early ; 
the  slight  cases  are  often  overlooked  till  much  damage 
has  been  done  by  improper  treatment. 

The  modes  in  which  illness  and  death  may  follow  are 
the  following.  The  usual  premature  escape  of  liquor 
amnii  leads  to  continuous  pressure  by  the  projecting 
parts  of  the  foetus  on  spots  of  the  uterine  wall, 
and  at  these  parts  the  uterine  wall  is  apt  to  get 
softened  and  inflamed.  The  cervix  being  deprived  of 
its  proper  dilator  is  apt  to  be  imperfectly  dilated, 
and  the  forcible  completion  of  dilatation  by  dragging 
the  head  through  it  may  tear  the  cervix.  The  pre- 
mature rupture  of  membranes  makes  the  first  stage 
in  any  case  long.  The  second  stage  is  prolonged 
because  the  uterus  has  to  overcome  bony  obstruction 
as  well  as  to  stretch  open  the  soft  parts.  Labour 
with  contracted  pelvis,  like  labour  with  normal  pelvis, 
is  more  dangerous  with  first  children  than  with  sub- 
sequent ones,  because  conditions  causing  difficulty  are 
more  likely  to  be  overlooked  when  the  guidance  is 
wanting  which  the  history  of  previous  labour  gives.  In 
contracted  as  in  normal  pelvis,  labour  is  more  dangerous 
with  male  than  with    female    children,   because    the 

L— 36 


1 62  Difficult  Labour 

heads  of  male  children  are  on  the  average  bigger 
than  those  of  female  children.  Labour  is  more 
dangerous  when  the  child  is  born  still  or  dead  than 
when  it  is  born  alive,  because  the  pressure  which 
kills  the  child  also  damages  the  mother.  Labours 
terminated  artificially  show  a  larger  mortality  than 
those  ended  naturally,  because  the  former  are  the 
worst  cases. 

Great  prolongation  of  labour  is  an  evil.    It 

means  great  muscular  effort,  protracted  pain,  long 
abstinence  from  food,  and  deprivation  of  sleep. 
Besides  these  injurious  influences,  there  is  in  con- 
tracted pelvis  not  only  stretching  and  tearing  open  of 
the  soft  parts,  but  bruising  of  them  by  compression. 

Greater  liability  to  postpartum  haemorr- 
hage.— The  great  strain  upon  the  uterus  in  forcing 
the  child  through  a  contracted  pelvis  leads  to  greater 
liability  to  exhaustion  of  its  contractile  and  retractile 
power;  and  this  after  delivery  means  post-partum 
haemorrhage.  If  the  patient  be  very  much  exhausted, 
either  from  haemorrhage  (or,  more  rarely,  without 
much  loss  of  blood),  she  may  die  from  shock  some 
hours  after  delivery,  and  after  complete  cessation  of 
bleeding. 

Greater  liability  to  puerperal  fevers.— In 

labour  with  a  pelvis  of  not  less  than  average  size  and 
a  child  of  not  more  than  average  size,  there  can  be 
no  destructive  compression  of  soft  parts  between  the 
foetal  head  and  the  pelvic  bones.  As  a  result  of  the 
bruising,  crushing,  tearing,  and  sloughing  of  the  soft 
parts  which,  in  labour  with  contracted  pelvis,  the  pres- 
sure of  the  head  on  the  pelvic  bones  produces,  there 
follows  a  greater  proneness  to  inflammation,  not  only 
at  the  injured  spots,  but  of  the  vagina  and  uterus, 
and  this  may  extend  to  the  peritoneum  and  cellular 
tissue  adjoining.  The  presence  of  islands  of  dead 
tissue,  which  have  to  be  separated  and  discharged; 
of  lacerations ;  of  vaginitis  and  endometritis  ;  leads 
to  more  discharge,  and  therefore  a  greater  liability 
to  retention  of    discharge    in   the    genital    passage. 


Dangers  of  Contracted  Pelvis.         163 

Retained  discharges  are  the  most  fertile  soil  for  the 
multiplication,  and  possibly,  also,  the  modification  in 
successive  generations,  of  microbes.  Hence  a  greater 
liability  to  saprgemia  and  septicaemia  after  labour 
with  contracted  pelvis.  Inflammation  may  extend 
to  the  veins,  and  phlebitis  may  lead  to  pyaemia. 

A  patient  with  contracted  pelvis  incurs  risk  of  these 
consequences,  even  if  delivery  is  effected  through  the 
natural  passage.  It  is  hardly  necessary  to  say  that  if 
the  contraction  is  of  such  a  degree  as  to  prevent  the 
child  from  passing  through  the  pelvis,  much  greater 
dangers  are  inevitable. 

If  labour  is  allowed  to  go  on  without  interference, 
the  uterus  passes  into  tonic  contraction  ;  and  then 
either  the  mother  dies  undelivered,  or  rupture  of  the 
uterus  or  vagina  takes  place.  These  effects  are  not 
peculiar  to  contracted  pelvis,  and  are  described  in 
chapters  XI.  and  xx. 


164 


CHAPTER  XIV. 

THE    DIAGNOSIS    OF    PELVIC    CONTRACTION. 

This  can  only  be  made  by  measurement  of  the  pelvis. 
But  you  may  get  information  from  the  history,  which, 
although  of  no  value  for  diagnosis,  should  make  you 
suspect  pelvic  contraction,  and  measure  the  pelvis. 

Value  Of  the  history. — The  known  causes  of 
pelvic  contraction  are 

Rickets. 
Osteomalacia. 
Inflammation  of  bones. 
Injuries. 

The  history  is  of  no  value  in  the  diagnosis  of  past 
rickets,  as  has  been  mentioned  in  describing  the 
rickety  pelvis. 

Osteomalacia  is  a  very  rare  disease  in  England, 
but  endemic  in  certain  localities  abroad.  The  bones 
of  the  extremities  are  so  bent,  that,  with  the  history 
that  this  bending  is  recent,  there  cannot  be  much 
difficulty  in  the  diagnosis. 

Inflammatory  disease  either  of  the  hip  joint,  the 
sacro-iliac  joint,  or  the  spine,  will  be  accompanied 
with  deformity  of  the  trunk  or  limbs  that  can  hardly 
fail  to  attract  attention. 

Fractures  of  the  pelvic  bones  are  among  the  rarest 
causes  of  pelvic  deformity ;  because  smashes  of  the 
pelvis  so  extensive  as  to  alter  its  measurements  are 
usually  accompanied  with  fatal  damage  to  the  soft 
parts. 

But  while  there  are  no  facts  about  the  history 
from  which  you  can  infer  the  size  and  shape  of  the 
pelvis,  even  if  you  can  suspect  the  existence  of  deform- 
ity, in  many  cases  of  pelvic  contraction  you  will 
get  no  history  of  disease  of  any  kind.  The  early 
history,  therefore,  may  be  an  indication  of  the  need  of 


Diagnosis  of  Pelvic  Contraction.       165 

examination,  nothing  more;  and  it  does  not  always 
give  even  this  help. 

Value  of  the  obstetric  history. — More  direct 

hints  may  be  gained  from  the  obstetric  history  of  the 
patient,  if  she  have  had  children  before.  But  this 
only  gives  materials  for  a  very  rough  guess  ',  for  the 
ease  or  difficulty  of  labour  depends  upon  a  great  many 
things  besides  the  size  and  shape  of  the  pelvis.  For 
instance,  the  size  of  the  child  ;  the  degree  of  ossification 
of  its  head  ;  the  amount  of  liquor  amnii,  and  the  time 
at  which  the  membranes  rupture  ;  the  strength  of  the 
pains  ;  the  position  of  the  child.  In  the  same  patient, 
from  different  combinations  of  these  different  factors, 
one  labour  may  be  very  easy  and  another  very 
difficult. 

The  configuration  of  the  body. — Except  in  the 
case  of  dwarfs  or  deformed  persons,  no  conclusion  as 
to  the  shape  of  the  pelvis  can  be  got  from  the  general 
configuration  of  the  body,  whether  the  patient  be  tall 
or  short,  robust  or  feeble.  Deformities  of  the  spine 
and  of  the  lower  limbs  make  us  suspect  the  presence 
of  the  pelvic  changes  which  usually  go  with  them  ; 
although  even  here  the  amount  of  pelvic  deformity 
depends  upon  the  age  at  which  the  disease  began. 

The  only  certain  information  about  the  size  and 
shape  of  the  pelvis  is  that  gained  by  pelvic  examina- 
tion and  measurement. 

Pelvimetry. — There  are  two  kinds  or  degrees  of 
pelvimetry,  which  I  will  call  complete  and  practical. 

Complete  pelvimetry  means  the  measurement  of 
the  pelvis  in  all  its  dimensions  as  precisely  as  is 
possible  during  the  patient's  life.  This  takes  a  long 
time.  It  needs  much  exposure  of  the  patient,  and 
much  manipulation  which  is  very  disagreeable  to  her. 
It  is  very  difficult  to  take  all  the  measurements 
accurately.  For  these  reasons  such  measurement  is 
not  submitted  to  in  English  private  practice,  and  very 
seldom  attempted  in  hospital  practice.  Still,  if  such 
measurement  enabled  us  to  manage  labour  very  much 
better,  it  would  be  our  duty  to  advise  our  patients  to 


166  Difficult  Labour. 

submit  to  the  unpleasantness,  and  to  let  us  measure  the 
pelvis  with  the  greatest  attainable  accuracy.  But  a 
very  minute  determination  of  the  size  and  shape  of  the 
pelvis  does  not,  in  the  present  state  of  our  knowledge, 
help  us  more  in  the  management  of  labour  than  the 
determination  of  a  few  simple  points.  This  is  because 
the  mechanical  difficulty  of  labour  depends  not  only 
on  the  size  of  the  pelvis,  but  on  the  size  and  hardness 
of  the  head.  We  have  no  way  of  exactly  measuring 
the  size  of  the  head.  We  can  tell  a  large  head  from 
a  small  one,  and  that  is  all.  We  cannot  judge  at  all, 
before  delivery,  as  to  how  compressible  the  head  is. 
While  we  are  ignorant  on  these  points,  we  do  not  gain 
much  by  knowing  the  size  of  the  pelvis  more  exactly 
than  to  within  a  quarter  of  an  inch  of  the  truth. 

Practical  pelvimetry. — By  practical  pelvimetry 
I  mean  the  taking  of  the  few  simple  measurements 
which  in  the  present  state  of  knowledge  are  enough  to 
guide  us  in  practice. 

The  pelvis  can  be  measured  more  easily  and  more 
exactly  immediately  after  delivery  than  at  any  other 
time.  Hence,  immediately  after  any  difficult  labour, 
the  pelvis  ought  to  be  measured,  in  order  that  the 
patient  may  be  rightly  advised  and  treated  in  sub- 
sequent pregnancies  and  labours.  If  she  has  been 
anaesthetised,  measure  the  pelvis  before  the  patient 
recovers  from  the  anaesthetic. 

When  a  patient  has  had  a  very  difficult  labour, 
and  finds  herself  pregnant  again,  she  sometimes  goes 
to  a  doctor  to  find  out  what  had  better  be  done.  It  is 
in  these  circumstances  that  pelvimetry  is  at  present 
most  often  called  for. 

A  patient  pregnant  for  the  first  time  very  seldom 
goes  to  her  doctor  early  in  pregnancy  that  he  may 
find  out  whether  any  difficulty  is  to  be  anticipated  in 
delivery  at  term,  and  take  the  necessary  steps  to 
obviate  it.  Yet  this  is  the  wisest  course  that  a 
pregnant  woman  can  take.  If  it  were  always 
followed,  many  labours  that  are  now  difficult  might  be 
made  easy. 


Pelvimetry. 


167 


Measurements. — The   measurements   taken  are 
external  and  internal.    The  external  measurements  are 


Fig.  72.— Duncan's  Callipers. 


taken  with  callipers.    The  best  callipers  for  the  pur-pose 
are  those  sold  as  Matthews  Duncan's  (Fig.  72). 


1 68  Difficult  Labour. 


a.  External  Measurements. 
1.  The    transverse   measurements   of  the 

false  pelvis. — There  are  two  of  these  : — 

(a)  The  intercristal. — This  is  taken  between  the 
iliac  crests  at  the  widest  part.  Put  the  points  of  the 
callipers  outside  the  iliac  crests  ;  press  them  together, 
and  move  them  backwards  and  forwards,  noting  the 
place  at  which  they  are  most  widely  separated. 
Measure  the  distance  at  this  point. 

(/3)  The  inter  spinous. — Put  the  points  of  the 
callipers  on  the  anterior  superior  iliac  spines.  Press 
the  thumbs  against  the  inner  surface  of  each  spine,  so 
that  the  point  of  the  callipers  shall  not  move  inwards 
beyond  the  spine. 

Another  mode,  which  I  think  more  liable  to  error, 
is  to  put  the  points  of  the  callipers  outside  the  iliac 
crests,  and  move  them  forwards  until  you  judge  they 
have  reached  the  anterior  end  of  the  crests — that  is, 
the  external  surface  of  the  spines.  This  is  the  method 
practised  in  Germany.  I  think  it  less  accurate, 
because  the  measurement  may  be  made  half  an  inch 
more  or  less,  according  to  where  the  operator  thinks 
the  anterior  surface  of  the  spine  ends  and  the  external 
begins. 

I  find  the  average  intercristal  measurement  in 
English  women  is  \\\  inches;  the  interspinous, 
according  to  the  method  first  given,  10  inches. 
According  to  the  second  method  it  would  be  10| 
inches  or  rather  more. 

These  measurements  are  easily  taken,  but  are  of 
little  service.  In  different  subjects  in  whom  the  true 
pelvis  is  of  full  average  size,  these  transverse  measure- 
ments may  differ  widely :  the  intercristal  may  be  as 
little  as  10,  or  as  much  as  14  inches;  the  interspinous 
as  little  as  9,  or  as  much  as  13  inches.  Hence,  unless 
the  transverse  measurements  are  very  small  indeed, 
no  inference  can  be  drawn  from  them  as  to  the  size 
of  the  true  pelvis.     Taken  in  relation  to  the   other 


External  Measurements.  169 

measurements  they  sometimes  help  us  in  judging  of 
the  shape  of  the  pelvis. 

In  extreme  rickety  flattening  of  the  pelvis  the 
shape  of  the  iliac  crests  is  altered,  so  that  their 
anterior  ends  do  not  curve  inwards  as  in  a  normal 
pelvis.  Small  variations  in  the  curve  of  the  crests  are 
found  in  normal  pelves  ;  so  that  a  variation  from  the 
average  amount  of  incurving  so  slight  that  it  requires 
measurement  to  detect  it,  is  of  no  importance.  An 
alteration,  so  great  that  the  spines  are  as  far  apart  as 
the  crests,  can  be  perceived  -without  measurement,  by 
feeling  the  crests ;  and  nothing  less  than  this  warrants 
an  inference  as  to  the  shape  of  the  true  pelvis.  The 
deformities  of  the  true  pelvis  that  deform  to  this 
extent  the  false  pelvis  are  easily  identified  without 
external  measurements. 

2.  The  external  conjugate. — This  is  measured 
from  the  depression  below  the  last  lumbar  vertebral 
spine  to  the  most  distant  point  of  the  anterior  surface 
of  the  symphysis  pubis.  Put  one  point  of  the  callipers 
below  the  spine,  let  an  assistant  hold  it  there,  while 
you  move  the  other  limb  of  the  callipers  up  and  down 
over  the  anterior  surface  of  the  symphysis  pubis. 
When  you  have  found  the  point  that  separates  most 
widely  the  limbs  of  the  callipers,  take  the  measure- 
ment. You  may  have  a  little  difficulty  in  finding  the 
depression  below  the  last  lumbar  spine.  Take  a 
horizontal  line  between  the  highest  points  of  the  iliac 
crests.  The  last  lnmbar  spine  lies  about  three  fingers' 
breadths  below  this;  and  it  is  about  an  inch  above  the 
line  joining  the  posterior  superior  iliac  spines. 

The  external  conjugate  measures  on  an  average 
about  J^  inches.  If  the  patient  be  very  fat,  it  may 
measure  more,  and  yet  the  true  conjugate  not  ex- 
ceed the  normal.  If  the  bones  are  slender,  and  the 
patient  thin,  it  may  be  as  little  as  7  inches,  and 
yet  the  pelvic  cavity  of  normal  capacity.  If  the 
external  conjugate  is  less  than  7  inches,  it  is  certain 
that  the  antero-posterior  diameter  of  the  pelvic  cavity 
is  less  than  it  ought  to  be;  but  the  size  of  the  external 


170  Difficult  Labour 

conjugate  does  not  tell  us  how  much  the  internal 
conjugate  is  shortened.  If  the  external  conjugate  is 
more  than  7  inches,  it  does  not  follow  that  the  pelvis 
is  not  contracted.  This  measurement  is  therefore 
sometimes  useful,  although  its  utility  is  small. 

It  is  known  as  the  diameter  of  Baudelocque. 
This  eminent  French  obstetrician  supposed  that  by 
deducting  from  it  3  inches  in  thin  women,  and  3J 
inches  in  the  well  nourished,  the  true  conjugate  might 
be  got.  This  has  been  shown  to  be  erroneous. 
Michaelis  found  that  in  living  subjects  the  difference 
between  the  external  and  internal  conjugates  varied 
from  2-f£  to  4^-  inches. 

The  posterior  interspinous  measurement.— 

This  is  taken  between  the  posterior  superior  iliac 
spines.  Let  the  patient  lie  on  her  face.  Trace  the 
iliac  crests  backwards.  The  posterior  half  of  the 
crests  runs  backwards,  inwards,  and  increasingly 
downwards.  Nearly  opposite  the  fourth  lumbar  spine 
the  crest  runs  almost  vertically  downwards,  but  still  a 
little  inwards.  About  an  inch  below  the  last  lumbar 
spine  you  will  feel  the  ridge  of  bone  suddenly  bend 
outwards.  At  this  bend  there  is  a  slight  thickening 
of  the  bone,  which  is  the  posterior  superior  iliac  spine. 

These  spines  are  easily  felt  in  thin  patients,  but  in 
fat  ones  it  is  very  difficult,  and  it  may  be  impossible, 
to  make  them  out.  In  most  patients  there  is  enough 
fat  over  them  to  make  it  difficult  to  be  sure  that 
the  callipers  are  accurately  applied.  Therefore,  unless 
the  patient  be  so  thin  that  the  bony  points  are 
plainly  visible  through  the  skin,  the  best  way  of 
measuring  accurately  is  to  mark  on  the  skin  the 
internal  and  lower  margin  of  each  spine.  Then, 
having  satisfied  yourself  that  the  marks  on  the  skin 
correspond  to  the  situation  of  the  bone  beneath,  apply 
the  callipers  to  the  marks. 

The  chief  value  of  this  measurement  is  its  relation 
to  the  anterior  interspinous.  In  the  normal  pelvis  it 
is  to  the  anterior  interspinous  as  1  to  3,  or  1  to  3|. 
If,  as  in  the  small  round  pelvis,  the  sacral  promontory 


External  Measurements.  171 

is  high  up,  the  posterior  spines  are  not  pulled  down 
and  in  so  much  as  usual,  and  the  anterior  ends  of  the 
iliac  crests  curve  inwards  a  little  more,  the  posterior 
measurement  is  larger  as  compared  with  the  anterior, 
and  the  ratio  is  more  than  1  to  3.  In  the  different 
forms  of  flattened  pelvis,  the  sacrum  being  sunk 
forwards,  the  posterior  spines  are  dragged  down  and 
in  to  an  unusual  extent,  while  the  anterior  ends  of 
the  crests  run  less  inwards.  Hence  the  ratio  of  the 
posterior  interspinous  to  the  anterior  is  less  :  in  the 
extreme  forms  it  may  be  as  little  as  1  to  5£. 

This  measurement  is  not  of  much  use  by  itself, 
nor  is  the  ratio  between  the  measurements.  But 
taken  with  other  measurements  it  sometimes  helps  us 
to  determine  the  kind  of  pelvis  we  are  dealing  with. 

Relation  of  sacral  to  posterior  iliac  spines. 

— At  the  same  time  that  you  take  the  posterior  inter- 
spinous measurement,  notice  another  point — viz. 
whether  the  posterior  sacral  spine  between  the  two 
posterior  superior  iliac  spines  is  on  the  same  level 
with  them,  or  sunk  below  them,  or  projecting  beyond 
them.  In  normal  pelves  it  is  nearly  on  the  same 
level ;  in  much  flattened  pelves  it  is  sunk  below  them ; 
in  pelves  of  the  round  type  it  projects  slightly  above 
them.  But  these  statements  only  apply  to  the 
majority  and  to  exceptionally  well-marked  deformities. 
In  the  slighter  fonns  this  peculiarity  is  not  marked 
enough,  or  constant  enough,  to  trust  to  for  diagnosis. 
It  must  be  considered  with  other  points. 

The  transverse  diameter  of  the  outlet.— In 

some  forms  of  contracted  pelvis — the  kyphotic,  the 
funnel-shaped,  and  the  osteomalacic — this  measure- 
ment is  important.  If  the  patient  is  not  in  labour  ifc 
had  better  be  made  externally.  The  tubera  ischii 
are  covered  with  such  a  thickness  of  soft  tissue  that 
it  is  difficult  to  apply  callipers  correctly  over  the 
bones.  Put  the  patient  on  her  knees  and  elbows,  and 
then,  with  the  fingers  outside,  assisted  if  necessaiy  by 
a  finger  in  the  rectum,  map  out  the  outline  of  the 
bones,  and  mark  it  on  the  skin  covering  them.    Make 


172  Difficult  Labour. 

sure  that  your  marks  correspond  to  the  bones,  and 
then  measure  between  the  marks  with  callipers.  The 
measurement  is  taken  between  the  two  ischial  tuber- 
osities, at  the  point  of  insertion  of  the  sacro-sciatic 
ligaments. 

Hardie's  measurement. — This  is  a  method  of 

measuring  the  true  conjugate  externally.  It  cannot  be 
used  after  the  third  month  of  pregnancy,  nor  within 
the  fortnight  following  delivery.  It  is  difficult  to 
do  it  in  nervous  women  and  in  fat  women.  Let  the 
patient's  bladder  be  emptied,  and  put  her  on  her  back, 
with  her  legs  drawn  up.  Put  your  hand  on  the 
abdomen,  with  the  tips  of  the  fingers  about  an  inch 
below  the  umbilicus.  Then  by  pressing  the  fingers 
backwards  you  will  feel  the  promontory  of  the 
sacrum.  Having  identified  the  promontory,  take 
a  measuring  tape ;  press  one  end  against  the  pro- 
montory, and  note  the  point  on  the  tape  which  crosses 
the  upper  border  of  the  symphysis.  Measure  the 
distance  between  this  point  and  the  end  pressed 
against  the  promontory.  This  measurement  gives  a 
result  inexact  in  two  ways :  (a)  the  result  is  shorter 
than  the  conjugate  by  the  thickness  of  the  abdominal 
wall  separating  the  finger  from  the  promontory,  and 
(b)  it  is  longer  by  the  extent  to  which  the  nearest 
point  of  the  symphysis  to  the  promontory  is  nearer 
than  the  centre  of  its  upper  margin.  In  women 
who  are  not  very  obese  these  two  errors  about  balance 
each  other. 

b.  Internal  Measurements. 

The  diagonal  conjugate. — The  measurement 
which  in  most  cases  is  the  important  one  is  the 
diagonal  conjugate.  It  is  important,  because  in  the 
commcn  forms  of  contracted  pelvis  it  is  the  only  one 
we  can  take  before  delivery.  From  it  we  can 
roughly  estimate  the  really  important  one,  the  true 
con  j  ugate. 

The  diagonal  conjugate  is  measured  from  the 
middle  of  the  sacral  promontory  to  the  lower  edge  of 
the  symphysis  pubis.     The  great  point  in  making  this 


Internal  Measurements.  173 

measurement  is  to  be  sure  that  the  finger  is  on  the 
promontory.  This  is  recognised  by  the  angle  which 
it  makes  with  the  lumbar  spine,  and  by  the  broad 
intervertebral  substance  which  separates  the  body  of 
the  last  lumbar  vertebra  from  that  of  the  first  sacral. 
A  "  false  promontory." — In  some  cases  there  is 
what  is  called  a,  false  promontory.  This  means  either 
that  the  sacral  concavity  from  above  downwards  is  so 
far  obliterated,  and  the  bony  union  of  the  first  and 
second  piece  of  the  sacrum  so  imperfect,  that  the  first 
piece  of  the  sacrum  forms  with  the  second  an  angle 
opening  backwards,  and  is  separated  from  the  second 
by  an  intervertebral  substance,  while  it  is  so  convex 
from  side  to  side  that  its  lateral  masses  retreat  like 
those  of  a  vertebra.  Or  it  may  be  that  the  last 
lumbar  vertebra  is  so  sunk  down,  and  joins  the  sacrum 
at  so  very  obtuse  an  angle  that  it  may  be  taken  for  a 
part  of  the  sacrum.  The  upper  border  of  the  last 
lumbar  vertebra  may  be  actually  nearer  the  symphysis 
than  the  lower.  Either  of  these  conditions  may  lead 
to  an  incorrect  judgment  as  to  the  situation  of  the 
promontory.  A  double  promontory  is,  as  a  rule,  only 
met  with  in  cases  of  flat  pelvis  and  considerable  pelvic 
deformity.  When  it  is  present,  we  should  measure 
to  the  upper  of  the  two  promontories,  and  deduct 
from  that  to  get  the  true  conjugate.  The  presence  of 
a  double  promontory  is  an  important  point  as  to  the 
difficulty  of  labour,  because  when  this  is  present  the 
resistance  to  the  passage  of  the  head  through  the 
brim,  instead  of  being  at  one  point  only,  is  present 
over  the  whole  breadth  of  a  vertebra. 

Inference  from  the  diagonal  conjugate  as 

to  the  true  Conjugate. — To  ascertain  exactly  the 
true  conjugate  from  the  diagonal  conjugate  we  need 
to  know  accurately  the  height  of  the  symphysis  and 
its  inclination  to  the  horizon.  If  we  could  ascertain 
these  points  precisely,  we  could  construct  a  triangle,  of 
which  we  should  know  the  length  of  two  sides,  and 
the  angle  between  them,  and  therefore  the  length  of 
the  third  side  could  easily  be  found.     The  higher  tne 


174  Difficult  Labour. 

symphysis,  and  the  greater  the  angle  formed  between 
it  and  the  true  conjugate,  or  the  less  the  angle 
between  it  and  the  diagonal  conjugate,  the  greater  the 
difference  between  the  two  conjugates. 

But  in  practice,  although  the  height  of  the 
symphysis  can  easily  be  measured  with  callipers,  the 
exact  inclination  of  the  symphysis,  and  therefore 
the  angle  which  it  forms  either  with  the  true  or 
diagonal  conjugate,  are  difficult  to  measure.  And  as 
there  are  other  factors  upon  which  the  difficulty  or 
case  of  delivery  depends  which  cannot  be  recognised 
with  exactness,  such  precision  in  the  measurement 
of  the  conjugate  does  not  at  present  help  us  much 
in  the  management  of  a  case.  A  measurement 
within  a  quarter  of  an  inch  is  close  enough  for 
practical  purposes.  Upon  the  average,  the  true 
conjugate  is  less  than  the  diagonal  by  about  three- 
fifths  of  an  inch.  This  average  is  only  widely  de- 
parted from  in  cases  of  great  deformity ;  and  in  them 
the  recognition  that  there  is  great  deformity  is  not 
difficult. 

If  the  head  has  not  entered  the  brim,  we  can 
measure  the  true  conjugate  directly  by  Johnson's 
method,  which  I  shall  presently  describe. 

In  pelves  of  natural  size  there  is  no  practicable 
way  of  measuring  the  transverse  diameter.  When 
greatly  shortened,  the  transverse  measurements  can 
be  taken  by  Johnson's  method. 

How  to  take  the  diagonal  conjugate.— The 

mode  of  taking  the  diagonal  conjugate  is  simple 
(Fig.  73).  Put  the  index  and  middle  fingers  of  the 
left  hand  into  the  vagina  (the  forefinger  alone  cannot 
usually  reach  far  enough),  and  press  them  up  behind 
the  cervix  uteri  until  you  feel  the  sacral  promontory. 
Then,  keeping  the  middle  finger  on  the  promontory, 
press  the  radial  side  of  the  forefinger  against  the  lower 
edge  of  the  symphysis.  Put  the  nail  of  the  right 
forefinger  beneath  the  pubic  angle,  holding  it  per- 
pendicular to  the  examining  index  finger,  mark  with 
the  nail  the  point  where  the  index  finger  touches  the 


Ho W  TO  TAKE  THE  DIAGONAL   CONJUGATE.      1 75 

lower  edge  of  the  symphysis.  Now  remove  the  two 
hands  together  without  separating  them.  Let  someone 
apply  a  tape  or  foot  rule,  and  measure  the  distance 
between  the  tip  of  the  middle  finger  and  the  place 
where  the  side  of   the  hand  touched  the  lower  edge 


Fig.  73.— Mode  of  Measuring  the  diagonal  Conjugate. 


of  the  symphysis.  This  distance  is  the  diagonal 
conjugate.  It  usually  measures  about  three-fifths  of 
an  inch  more  than  the  true  conjugate.  Therefore,  in 
most  pelves,  by  deducting  half  an  inch  (a  more  con- 
venient fraction),  you  get  from  it  the  true  conjugate. 
If,  when  you  have  pushed  the  fingers  up  as  far  as  you 


176  Difficult  Labour. 

can  without  causing  pain  to  the  patient,  you  still 
cannot  feel  the  promontory,  it  is  probable  that  the 
conjugate  diameter  is  not  contracted,  and  certain  thai 
it  is  not  much  contracted.  You  can  feel  the  pro* 
montory  in  almost  any  patient  if  you  press  up  strongly 
enough. 

In  the  commonest  deformity,  viz.  slight  flattening 
of  the  pelvis,  this  mode  of  estimating  the  true  con- 
jugate is  near  the  truth,  and  these  are  the  cases 
in  which  it  is  most  important  to  know  the  measure- 
ment of  the  conjugate.  In  the  small  round  pelvis, 
owing  to  the  high  position  of  the  sacrum,  the  deduc- 
tion to  be  made  is  greater;  but  here  the  conjugate  is 
not  so  important  as  in  the  flat  pelvis.  In  the  extreme 
forms  of  flat  pelvis  the  deduction  to  be  made  is  some- 
times more,  sometimes  less ;  but  in  these  cases  the 
measurement  can  be  otherwise  made. 

Direct  measurement  of  the  conjugate. — This 

can  be  done  after  delivery,  and,  in  cases  of  great 
deformity,  before  delivery,  by  Johnson's  method.* 

To  measure  in  this  way  you  must  know  the 
measurements  of  your  own  hand.  The  following 
measurements,  which  Mr.  Johnson  gave,  are  those  of 
a  man's  hand  of  average  size.  Measure  your  own 
hand,  and  see  if,  and  how  much,  the  measurements 
differ  from  those  here  given  : — 

1.  The  fingers  being  bent  into  the  palm,  and  the 
thumb  extended  and  applied  close  to  the  middle  joint 
of  the  forefinger,  the  distance  between  the  end  of  the 
thumb  and  the  outside  of  the  middle  joint  of  the  little 
finger  is  four  inches  (Fig.  74). 

2.  In  the  above  position,  the  distance  from  the 
thumb  at  the  root  of  the  nail,  in  a  straight  line  to  the 
outside  of  the  middle  joint  of  the  little  finger,  is  three 
inches  and  a  half  (Fig.  75). 

3.  The  fingers  being  in  the  same  position,  and  the 
thumb  laid  obliquely  along  the  joints  next  the  nails  of 


*  So    called    after  Mr.    Robert  Wallace  Johnson,   who  first 
described  it  in  "A  System  of  Midwifery,"  London,  1769. 


Fig.  74. — Direct  Pelvimetry  :  measurement,     Pig.  75.— Direct  Pelvimetry  :  measurement, 
four  inches.  three  inches  and  a  half. 


Fig.  76.— Direct  Pelvimetry  :  measurement,      Fig.  77.— Direct  Pelvimetry  :  measurement, 
three  inches  and  a  quarter.  three  inches. 

M— 3(i 


i78 


Difficult  Labour. 


the  first  two  fingers  and  bent  down  upon  them,  the 
distance  between  the  outside  of  the  middle  joint  of  the 
forefinger  and  the  outside  of  that  of  the  little  finger 
is  three  inches  and  a  quarter  (Fig.  76). 

4.  The  hand  being  opened,  and  the  fingers  held 
straight,  the  whole  breadth  from  the  middle  joint  of 
the  forefinger  to  the  last  joint  of  the  little  finger  is 
three  inches  (Fig.  77). 

5.  The  fingers  being  so  far  bent  as  to  bring  their 
tips  to  a  straight  line, 
their  whole  breadth  across 
the  joint  next  to  the  nails 
is  two  inches  and  a  half 
(Fig.  78). 

6.  When  the  first 
three  fingers  are  thus 
bent,  their  breadth  across 
the  same  joint  is  two 
inches. 

7.  The  breadth  of  the 
first  two,  across  the  nail 
of  the  forefinger,  is  one 
inch  and  a  quarter. 

In  any  case  in  which 
labour  has  been  difficult 
you  ought  to  measure  the 
conjugate  in  this  way 
either  during  or  immedi- 
ately after  the  third  stage 
of  labour.  If  the  pelvis 
is  so  contracted  that  the 
head  cannot  enter  the 
brim,  you  can  measure  in  this  way  during  the  first 
staple  of  labour.  Put  your  fingers  and  thumb  together 
in  the  shape  of  a  cone,  and  put  the  whole  hand 
into  the  vagina  and  up  to  the  pelvic  brim.  Then 
put  your  hand,  in  the  different  positions  described,  in 
the  conjugate  diameter,  and  see  which  measurement 
fills  that  diameter.  Be  certain  that  the  part  of 
the  hand  by  which  you  are  taking  the  measurement 


Kig.  78.— Direct  Pelvimetry:  measure 
ment,  two  inches  and  a  half. 


Direct  Pelvimetry.  179 

is  across  the  narrowest  part  of  the  brim,  and  not  lying 
obliquely  to  it;  for  this  is  the  chief  source  of  error  in 
this  mode  of  measurement. 

Any  other  internal  diameters  of  the  pelvis  that  are 
contracted  to  four  inches  or  less  can  be  measured  in 
this  way  with  accuracy. 


i8o 


CHAPTER    XV. 

THE     MECHANISM     OP     LABOUR     WITH     CONTRACTED 
PELVIS. 

In  what  cases  and  why  knowledge  of  the 

mechanism  is  important. — The  kinds  of  contracted 
pelvis  that  alter  the  mechanism  of  labour  in  ways 
that  have  been  well  ascertained  by  observation,  are 
the  common  and  slight  forms.  Descriptions  of  the 
mechanism  of  labour  in  the  rare  forms  of  contracted 
pelvis  are  based  either  on  very  few  cases,  or  altogether 
upon  theory.  In  cases  of  contraction  of  the  pelvis 
so  great  as  to  prevent  the  birth  of  a  living  child,  the 
only  mechanism  that  needs  study  is  the  mechanism  of 
dragging  out  a  collapsed  or  crushed  head. 

The  two  commoner  and  slighter  forms  of  con- 
tracted pelvis,  viz.  the  flat  and  theism  all  round 
pelvis,  affect  the  mechanism  of  labour  differently.  A 
study  of  this  difference  is  important,  not  only  because 
a  knowledge  of  the  natural  mechanism  guides  treat- 
ment, but  because  observation  of  the  mechanism  helps 
greatly  in  the  diagnosis  of  the  kind  of  contracted 
pelvis  with  which  we  are  dealing. 

1.  The  Mechanism   of  Labour   with  Flattening 
of  the  Pelvis. 

It  makes  no  difference  from  the  point  of  view 
of  mechanism,  whether  the  flattening  is  rickety  or 
non-rickety  :  the  mechanism  depends  on  the  degree  of 
contraction,  not  upon  its  cause.  But  the  rickety  pelves 
are  the  most  contracted. 

Effects  during  pregnancy. — The  liability  to 

incarceration  of  the  retroverted  gravid  uterus  in  the 
fourth  month  of  pregnancy,  and  the  greater  mobility  of 
the  child,  have  been  mentioned.  The  sinking  forward 
of  the  sacrum  is  often  accompanied  with  lordosis  of  the 


Mechanism  with  Flat  Pelvis.  181 

spine,  and  this  pushes  the  uterus  forward,  and  helps, 
together  with  the  greater  mobility  of  the  uterus  and 
the  child,  to  make  pendulous  belly  more  frequent. 
Malpresentations — face,  brow,  breech,  footling,  oblique 
positions,  prolapse  of  cord  and  of  hand — are  all  more 
frequent  with  flat  pelvis. 

Effect  on  first  Stage. — The  simple  flat  pelvis 
seldom  offers  such  great  contraction  as  to  prevent 
the  birth  of  a  living  child.  The  deformity  hinders 
the  entry  of  the  head  into  the  pelvis.  It  makes  the 
first  stage  long,  because  the  membranes  often  rupture 
prematurely ;  and  the  second  stage  also  tedious,  be- 
cause the  long  first  stage  often  exhausts  the  uterus, 
and  because  the  head  often  does  not  pass  the  brim 
until  some  time  after  full  dilatation  of  the  os.  But 
in  a  simply  flat  pelvis  there  is  no  difficulty  from  the 
pelvic  bones  after  the  head  has  passed  the  brim. 

The  diagnosis  ought  to  be  made  early,  first  by 
finding  by  abdominal  palpation  that  the  greatest 
diameter  of  the  head  is  above  the  brim,  and  then  by 
measurement  of  the  conjugate. 

Transverse    position   of  head. — When   the 

head  enters  the  brim,  the  sagittal  diameter  lies  trans- 
versely. This  was  noticed  by  Srnellie.*  It  is  because 
the  projecting  promontory  prevents  there  being  room 
for  the  head  in  either  oblique  diameter.  The  project- 
ing promontory  throws  forward  the  oblique  diameters, 
so  that  if  the  head  presents  in  one  of  them,  the 
parietal  bone  which  lies  opposite  the  symphysis 
meets  with  a  resistance  which  presses  it  into  the 
transverse  diameter.  The  head  passes  the  brim  with 
its  long  diameter  lying  parallel  with  the  transverse 
diameter  of  the  pelvis,  but  in  front  of  it  (Fig.  79), 
and  if  the  resistance  has  been  great,  the  parietal 
bone  lying  posteriorly  is  marked  with  a  dint  running 
parallel  with  the  coronal  suture.  If  the  pelvis  is 
not  merely  flat,  but  generally  contracted,  so  that  in 
the  transverse  diameter  of  the  cavity  there  is  not 

•  N.S.S.Edn.,  vol.  ii.  pp.  331,  348    et  seq. 


182 


Difficult  Labour. 


room  for  the  occipito-frontal  diameter  of  the  head, 
then  as  the  head  descends  it  will  become  more 
flexed  and  rotated  into  the  oblique  diameter  of 
the  pelvic  cavity  :  and  the  mark  on  the  head  caused 
by  the  promontory  will  run  from  in  front  of  the 
parietal  bone  forwards  towards  the  malar  bone.  But 
unless  there  is  transverse  contraction  as  well  as  con- 
traction in  the  conjugate,  the  rotation  forward  of  the 


Fig.  79.— Position  in  which  the  Head  enters  the  Brim  of  the  Flat  Pelvis. 
a,  Transverse  diameter  of  pelvis;  n,  diameter  in  which  long  diameter  of  bead  lies. 

occiput  does  not  take  place  till  the  head  has  quite 
passed  the  brim. 

Incomplete  extension  of  head. — This  trans- 
verse position  of  the  head  is  the  most  constant 
peculiarity  of  labour  with  flat  pelvis.  The  next  most 
frequent  alteration  of  the  normal  mechanism  is,  that 
together  with  the  transverse  position  of  the  head, 
there  is  sufficient  extension  to  bring  the  anterior  fon- 
tanelle  low  down.  We  find  it  easily  near  the  middle 
line,  while  the  posterior  fontauelle  is  high  up  and 
reached  with  difficulty.  This  is  because  the  greatest 
transverse  diameter  of  the  head  (the  bi- parietal)  is 
behind,  and  hence  the  descent  of  the  hinder  part  of 
the  head  is  most  hindered.  A  greater  degree  of  this 
extension  leads  to  brow  or  face  presentations,  which 
(it  has  been  pointed  out   in  chapter   n.),   are  more 


Obliquity  of  Naegele.  183 

common  in  contracted  than  in  normal  pelves.  If  the 
delivery  take  place  naturally,  the  occiput  gradually 
sinks  as  the  head  passes  the  brim  ;  after  it  has  passed 
the  brim  the  occiput  sinks  still  more  ;  and  when  it  en- 
counters the  resistance  of  the  pelvic  floor  it  moves  to 
the  front,  and  delivery  takes  place  as  in  a  normal 
labour.  It  will  be  plain  that  for  the  head  to  enter  in 
this  way  the  transverse  diameter  of  the  pelvis  must 
be  large  enough  to  admit  the  occipitofrontal  measure- 
ment of   the   foetal   head.     A  very  large  transverse 


Fig.  80. — Obliquity  of  Naegele  :  the  sagittal  suture  near  the  sacral 
promontory. 

diameter  will  favour  the  production  of  a  brow  presenta- 
tion, in  which  the  occipito-mental  diameter  lies  across 
the  pelvis.  This  will  be  favoured  by  obliquity  of  the 
uterus  towards  the  side  to  which  the  abdominal  aspect 
of  the  child  looks,  but  will  not  be  prevented  by 
obliquity  in  the  opposite  direction. 

Obliquity  Of  Naegele. — That  is,  one  parietal 
bone  is  lower  down  than  the  other.  This  is  present  in 
nearly  all  cases  of  flat  pelvis.  In  the  great  majority  of 
cases  the  anterior  parietal  bone  is  the  lower,  so  that 
the  sagittal  suture  is  nearer  to  the  sacral  promontory 
than  to  the  symphysis  pubis  (Fig.  80).  This  is  because 
the  jutting  forward  of  the  promontory  hinders  the 
descent   of    the    posterior-lying    parietal     bone.      So 


184  Difficult  Labour. 

regular  is  this,  that  it  has  even  been  said  that  the 
distance  between  the  sagittal  suture  and  the  sacral 
promontory  is  the  best  guide  to  the  proportion 
between  the  size  of  the  head  and  that  of  the  pelvis.* 
This  obliquity  may  reach  such  a  degree  that  the  ear 
gets  behind  the  symphysis.  If  the  labour  ends 
naturally,  the  anterior-lying  parietal  bone  becomes 
fixed  against  the  symphysis  pubis,  and  with  this  as  a 
centre  of  rotation  the  head  rotates  about  its  long 
axis,  so  that  the  posterior  parietal  bone  is  squeezed 
past  the  promontory :  and  it  is  bruised  and  often 
dinted  where  the  most  jutting  part  of  the  promon- 
tory pressed,  the  bruises  and  dints  marking  its  path. 
While  this  rotation  is  taking  place  the  occiput  de- 
scends j  and  as  soon  as  the  greatest  transverse 
diameter  that  lies  in  the  brim  has  got  past  the 
promontory  the  occiput  begins  to  turn  to  the  front. 
The  head  may  even,  in  great  contraction  of  the  brim, 
present  so  much  inclined  that  the  parietal  bone  occupies 
the  conjugate,  the  sagittal  suture  being  above  the  pro- 
montory. Then,  as  the  posterior  parietal  bone  slips 
down,  a  pressure-mark  is  left  beginning  at  the  upper 
part  of  the  anterior  parietal  bone,  and  extending 
across  the  sagittal  suture,  and  down  the  posterior 
parietal  bone,  parallel  with  the  coronal  suture.  The 
bruising  and  crushing  of  the  maternal  parts  opposite 
the  promontory  have  been  described  elsewhere. 

Posterior  parietal  obliquity.  —  The  above- 
described  usual  and  favourable  obliquity  is  called  the 
"  anterior  parietal  position."  The  opposite,  in  which 
the  sagittal  suture  is  nearer  the  symphysis  pubis,  is 
called  the  "  posterior  parietal  position,"  is  unfavourable 
to  delivery,  and  is  much  rarer  (Fig.  81).  Pendulous 
belly  produces  anterior  parietal  obliquity  even  without 
contracted  pelvis  :  now  pendulous  belly  is  rare  in  first 
pregnancies,  and  therefore  the  rare  posterior  parietal 
obliquity  occurs  generally  in  first  labours.  It  is  more 
likely  to  occur  if  the  promontory  is  sunk  very  low, 

*  Litzmann,  p.  103. 


Posterior  Parietal  Obliquity.  185 

because  it  then  does  not  so  soon  arrest  the  descent 
of  the  posterior  parietal  bone. 

Posterior  parietal  obliquity  is  naturally  produced, 
when  bony  obstruction  is  absent,  by  the  fact  that  the 
axis  of  the  pregnant  uterus  lies  behind  the  line  of 
the  axis  of  the  pelvic  inlet.  In  easy  and  premature 
labours  the  head  often  descends  into  the  pelvis  in  a 
position  of  posterior  parietal  obliquity  (Fig.  82).  But 
in  a  flat  pelvis  the  jutting  promontory  keeps  back  the 
posterior  parietal  bone. 

When  the  head  presents  in  a  flat  pelvis  with  this 


Fig.  81. —Posterior  parietal  Obliquity  :  sagittal  suture  nearer  the 
symphysis  pubis  than  the  promontory. 

obliquity  it  passes  the  brim  in  the  following  manner. 
The  pains  drive  down  the  anterior  parietal  bone,  and 
as  it  descends  the  posterior-lying  parietal  bone  moves 
up,  and  then  first  the  anterior  parietal  eminence 
passes  the  brim,  then  the  posterior.  Sometimes  the 
side  of  the  head  opposite  the  promontory  remains 
fixed,  and  the  head  rotates  round  this  point  as,  when 
it  is  in  the  anterior  parietal  position,  it  rotates  round 
the  symphysis.  But  this  only  happens  when  the  foetal 
head  is  small  and  soft,  so  that  it  becomes  indented 
instead  of  moving  up.  If  the  posterior  parietal 
position  persists,  and  is  not  removed  in  either  of 
these  ways,  perforation  or  turning  will  be  necessary. 


1 86 


Difficult  Labour. 


Mechanism  with  the  face  presenting.— In 

flat  pelvis  face  presentation  is  commoner  than  in 
normal  pelvis  ;  and  in  such  cases  the  face  lies  trans- 
versely, the  chin  towards  one  side,  the  forehead  to  the 
other.  "We  have  no  observations  of  the  mechanism 
of  the  passage  through  the  brim  in  such  cases.  In 
my  own  practice  I  have  always  anticipated  difficulty 
in  such  cases  by  turning.     Remember  this  effect  of 


Pig.  82. — Posterior  parietal  Obliquity  in  easy  Labour  with  small 
Child.    (From  a  frozen  section  after  Pinard  and  Varnier.) 


the  flat  pelvis,  and  if  you  find  the  face  lying  trans- 
versely suspect  flattening  of  the  pelvis. 

Mechanism  with  the  after-coming  head.— 

The  after-coming  head  generally  enters  the  flat  pelvis 
transversely  ;  although,  if  it  be  small,  it  may  do  so  in 
an  oblique  diameter.  The  diameter  which  lies  in  the 
conjugate  is  a  transverse  diameter  in  front  of,  and 
smaller  than,  the  bi-parietal,  which  lies  on  one  side  of 
the  sacral  promontory.  If  the  conjugate  is  so  small 
as  to  offer  resistance  to  the  diameter  engaged  in  it, 
the  head   becomes  partly  extended.     But   when  the 


Effects  on  Fcetal   Head.  187 

head  moves  onwards,  the  bi-parietal  diameter  is  held 
back  more  than  the  shorter  diameter  in  front  of  it, 
and  so  the  head  becomes  flexed.  If  the  natural 
mechanism  is  not  interfered  with,  the  advance  of  the 
posterior-lying  parietal  bone  is  arrested  by  the  sacral 
promontory,  and  the  side  of  the  head  which  lies 
anterior  rotates  round  the  promontory.  There  is  thus 
a  close  analogy  between  the  modes  of  passage  of  the 
fore-coming  and  the  after-coming  head  through  a  flat 
pelvis.  In  both  cases  the  head  lies  transversely  ;  in 
both  the  head  is  at  first  more  extended  than  with  a 
normal  pelvis  ;  in  both  there  is  obliquity  produced  by 
the  holding  back  of  the  posterior-lying  parietal 
bone.*  The  head  may  be  detained  above  the  brim  ; 
and  in  such  cases  we  cannot  watch  the  natural 
mechanism,  because,  for  the  sake  of  the  child's  life, 
prompt  delivery  is  needed.  If  the  head  is  delivered 
by  jaw  traction,  and  the  chin  is  pulled  down  while 
the  greatest  diameter  of  the  head  remains  above 
the  brim,  then  first  the  bi-temporal  and  then  the 
bi-parietal  diameters  pass  the  conjugate.  If  the  head 
is  delivered  by  forceps,  the  head  may  pass  the  brim 
without  increased  flexion,  so  that  the  bi-temporal 
diameter  is  the  largest  that  lies  in  the  conjugate.  The 
posterior-lying  parietal  bone  will,  if  much  force  is 
used,  be  grooved  by  the  jutting  promontary,  and  this 
groove  will  show  the  way  in  which  the  head  moved. 
If  the  body  should  be  delivered  with  its  abdominal 
surface  forwards,  the  chin  may  catch  on  the  pubic  bone. 
The  difficulty  of  delivery  will  be  great,  and  as  slow 
delivery  means  certain  death  to  the  child,  if  delivery 
is  not  quick  the  perforator  should  terminate  the  case. 

Effects  on  the  foetal  head. — The  caput  suc- 

cedaneum  is  less  marked  in  this  than  in  the  small 
round  pelvis.  Circumscribed  pressure  marks  in 
the  skin  and  dinting  of  the  foetal  skull  are  com- 
moner, because  in  the  small  round  pelvis  the  pro- 
jection forwards  of  the  promontory  is  not  so  great. 

*  See    Goodell,    Transactions    of    the    International    Medical 
Congress,  Philadelphia,  1876. 


1 88  Difficult  Labour. 

Great  overriding  of  the  bones  at  the  sutures  is 
less  common  in  flat  pelvis  than  in  the  small  round 
pelvis,  because  in  the  former  the  pressure  is  more 
localised,  and  therefore  dints  the  bone  instead  of 
depressing  the  whole  bone.  Anteroposterior  dis- 
placement of  the  two  lateral  halves  of  the  cranium 
is  more  common  in  flat  pelvis.  Flattening  of  tho 
posterior-lying  parietal  bone  is  almost  always  pro- 
duced, with  corresponding  arching  of  the  opposite 
side  of  the  cranial  vault.  In  the  slighter  forms  of 
contracted  pelvis  there  is  a  gutter-like  depression 
where  the  head  scraped  past  the  promontory  ;  which 
in  the  case  of  the  after-coining  head  runs  from  the 
anterior  inferior  angle  of  the  parietal  bone  upwards 
and  backwards  to  the  parietal  eminence :  in  the 
greater  contractions  there  is  a  funnel-shaped  dint  where 
the  head  stuck  for  a  time  opposite  the  promontory. 

2.   The  Mechanism   op  Labour  with   the  small 
round  Pelvis. 

The  broad  distinction  between  the  round 

and  the  flat  pelvis.— The  mechanism  of  labour 
with  the  small  round  pelvis  is  practically  the  same  as 
that  with  a  normal  pelvis  but  a  too  large  fetal  head. 
If  the  foetal  head  is  too  large,  the  pelvis  may  be 
said  to  be  relatively  small.  This  mechanism  is  quite 
different  from  that  with  the  flat  pelvis.  The  great 
broad  difference  is  this,  that  with  the  flat  pelvis  the 
difficulty  is  at  the  brim  :  the  head  cannot  easily 
enter  the  pelvis.  When  it  has  entered  the  pelvis 
all  mechanical  difficulty  is  over.  With  the  small 
round  pelvis,  on  the  contrary,  the  head  can  enter 
the  pelvis,  but  cannot  easily  pass  through  it ;  there  is 
difficulty  throughout  the  whole  passage  of  the  head. 

During  pregnancy. — In  the  small  round  pelvis 
the  promontory  of  the  sacrum  does  not  overhang,  and 
thei'efore  there  is  not  the  greater  liability  to  in- 
carceration of  the  retro  verted  gravid  uteris  that  the 
flat  pelvis  brings  with  it.  From  the  fact  just 
mentioned,  that  in  the  small  round  pelvis  the  head 


Mechanism  with  Small  Round  Pelvis.    189 

can  engage  in  the  brim,  it  follows  that  there  is  not 
with  the  small  round  pelvis  the  liability  to  obliquity 
of  the  uterus  or  to  pendulous  belly  that  the  flat 
pelvis  brings  with  it.  Nor  is  there  so  great  a 
tendency  to  transverse  presentations,  or  to  prolapse  of 
the  hand  or  of  the  funis.  The  small  size  of  the  pelvis 
may  prevent  the  occiput  from  coming  down,  because 
the  greatest  transverse  diameter  of  the  head,  viz.  the 
bi-parietal,  is  nearer  the  occiput  than  the  sinciput. 
Hence  the  small  round  pelvis  favours  the  occurrence 
of  fronto-cotyloid  occipito-posterior  positions,  of  brow 
presentations,  and  of  face  presentations. 

First  Stage  of  labour. — In  the  small  round 
pelvis,  as  the  head  can  fill  up  the  pelvic  inlet,  and  its 
advanced  part  can  press  into  the  os  uteri,  there  is  not 
the  tendency  to  premature  rupture  of  membranes.  If 
the  pains  are  very  strong,  the  head  may  be  so  jammed 
into  the  pelvis  as  to  nip  the  cervix  all  round  between 
it  and  the  pelvic  bones,  and  so  prevent  its  retraction 
over  the  head. 

Extreme  flexion. — In  the  small  round  pelvis 
the  oblique  diameters  are  not  encroached  upon.  The 
head  therefore  enters  the  pelvis  in  one  of  the  oblique 
diameters.  But  whereas,  in  a  normal  pelvis,  the  head 
meets  with  no  resistance  from  the  bones,  and  the 
work  of  labour  consists  solely  in  the  dilatation  of  the 
soft  parts,  in  the  small  round  pelvis  the  head  can  only 
pass  by  its  position  being  closely  adapted  to  the  pelvis. 
The  sub-occipito-frontal  diameter  measures  on  the 
average  four  inches.  Now  if  the  oblique  diameter  of 
the  pelvis  measures,  say,  four  inches  and  a  quarter, 
and  is  by  the  soft  parts  made  still  smaller,  you  will 
see  that  the  head  can  only  enter  it  by  being  extremely 
flexed,  so  that  the  sub-occipito-frontal  diameter,  and  no 
lai'ger  one,  shall  occupy  the  brim.  If  it  be  not  com- 
pletely flexed,  a  larger  diameter  than  the  sub-occipito- 
frontal  will  lie  across  the  pelvis,  and  entry  be 
impossible.  Hence  with  the  small  round  pelvis  there 
is  extreme  flexion  of  the  head,  so  that  the  posterior 
fontanelle  is  lower  down,  and  nearer  the  middle  of  the 


190  Difficult  Labour. 

pelvis  than  usual :  and  this  flexion  occurs  when  the 
head  is  higher  up,  because  it  is  produced  by  the 
resistance  of  the  pelvic  brim,  instead  of  by  that  of  the 
os  uteri,  as  in  normal  labour. 

Early  rotation, — In  labour  with  a  normal 
pelvis  the  turn  of  the  head  into  the  antero  posterior 
diameter  of  the  pelvis  (internal  rotation)  does  not 
take  place  until  quite  late,  often  not  till  the  head  is 
distending  the  perineum.  This  is  because  the  turn 
here  depends  upon  the  soft  parts  and  not  upon  the 
bones.  But  in  the  small  round  pelvis  the  head  cannot 
get  through  unless  it  accommodates  itself  to  the 
bones.  Hence  the  turn  forward  takes  place  earlier, 
because  it  is  produced  by  the  narrowing  of  the 
transverse  diameter  of  the  pelvis  at  the  outlet,  which 
obliges  the  long  diameter  of  the  head  to  go  into  the 
long  diameter  of  the  outlet.  This  rotation  is  not  only 
earlier,  but  more  complete.  In  labour  with  a  normal 
pelvis  and  a  small  child,  internal  rotation  may  be 
incomplete  or  not  take  place  at  all,  but  the  child  be 
born  in  an  oblique  diameter.  If  the  pelvis  is  small 
and  the  child  large,  rotation  must  be  complete. 

Variability  of  position. — If  the  foetal  head  is 
not  impacted  in  the  pelvis,  it  advances  during  each 
pain,  and  recedes  in  the  interval.  Now  if  the  advance 
and  recession  be  considerable,  the  head  may  during 
the  pain  be  driven  so  far  down  that  the  occiput  is 
obliged  to  turn  forward ;  but  in  the  interval  it  may 
recede  so  much  that  it  gets  into  a  part  of  the  pelvis  in 
which  there  is  most  room  for  the  long  diameter  of  the 
head  in  the  oblique  diameter.  Then  the  occiput  will 
turn  back  again  as  the  head  recedes.  This  change- 
ability in  the  direction  of  the  long  diameter  of  the 
head  is  characteristic. 

Effect  on  the  soft  parts. — When  the  head  is 
jammed  into  the  cavity  of  a  small  round  pelvis,  it 
is  pressed  upon  all  round,  instead  of,  as  in  the  flat 
pelvis,  only  where  it  is  opposed  to  the  sacral  pro- 
montory and  the  symphysis  pubis.  Hence  the 
circulation  through  the  scalp  is  interfered  with  at  the 


Effects  on   Head.  191 

girdle  of  pressure,  and  the  part  in  advance,  that  is 
not  pressed  on,  becomes  cedeuiatous.  In  other  words, 
a  large  caput  succedaneum  is  formed  during  the  second 
stage  of  labour.  The  pressui*e  that  produces  oedema 
of  the  scalp  also  produces  oedema  of  the  maternal 
soft  parts  below  the  seat  of  pressure.  This  is  chiefly 
evident  in  the  labia,  because  they  are  visible  and  are 
formed  of  loose  tissue,  so  that  they  can  swell.  The 
disturbed  circulation  hinders  the  secretion  of  the 
vaginal  and  vulvar  glands,  and  the  vagina  becomes 
dry.     It  feels  hot,  dry,  and  swollen. 

Absence  of  Naegele  obliquity.— The  obliquity 
of  Naegele  is  characteristic  of  the  flat  pelvis.  In  the 
small  round  pelvis  the  obliquity  of  Naegele  is  hardly 
ever  found.  This  is  because  the  sacral  promontory 
does  not  project  so  much,  and  therefore  does  not 
hinder  the  descent  of  the  posterior-lying  parietal 
bone.  At  the  beginning  of  labour  it  is  common  for 
the  posterior  parietal  bone  to  be  slightly  lower  down, 
so  that  the  sagittal  suture  is  rather  nearer  the  pubis 
than  the  sacrum.  This  is  always  the  case  if  the  long 
axis  of  the  uterus  is  much  behind  the  line  of  the  axis 
of  the  pelvic  brim,  and  there  is  no  hindrance  to  the 
entry  of  the  head.  If  in  the  small  round  pelvis 
the  head  enters  in  this  position,  in  the  progress  of 
labour  the  anterior  parietal  bone  descends  with  much 
less  difficulty  than  in  the  flat  pelvis.  A  very  great 
degree  of  this  posterior  parietal  obliquity  is  always 
unfavourable  in  the  small  round  pelvis,  as  in 
the  flat  pelvis. 

Breech  presentations. — Breech  presentations  do 
not,  in  the  small  round  pelvis,  present  greater  diffi- 
culties than  head  presentations,  unless,  by  untimely 
pulling,  the  arms  or -head  get  extended.  If  this 
happens,  the  smaller  space  in  which  you  have  to  work 
will  make  the  task  of  getting  down  the  arms  and 
pulling  down  the  head  more  difficult  than  usual. 

Rupture  Of  the  Uterus  is  seldom  met  with  from 
the  small  round  pelvis ;  partly  because  great  con- 
traction of  this  form  is  rare,  and  partly  because  the 


192 


Difficult  Labour. 


wedging  in  the  pelvis  of  the  head,  the  swelling  of  the 
labia,  etc.,  soon  demonstrate  the  need  for  assistance. 

Effects  on  head. — The  pressure  effects  on  the 
head  consist  chiefly  of  moulding  and  the  great  caput 
succedaneum.  Red  stripes  and  ecchymoses  are  some- 
times seen ;  but  dints  and  furrows  in  the  bones  are 
very  rare.  The  most  characteristic  local  pressure  mark 
is  a  red  stripe  caused  by  the  pressure  of  the  promon- 
tory, extending  from  the  parietal  bone  towards  the  jaw 
or  eye,  and  produced  by  the  side  of  the  head  and  face 
scraping  past,  the  promontory  as  the  occiput  descends. 
The  head  is  squeezed  so  that  it  is  lengthened  in 
its  longest  diameter.  The  occiput,  being  the  part  first 
exposed  to  pressure,  is  pressed  under  the  parietal 
bones.  The  posterior-lying  parietal  bone  is  by  the 
pressure  of  the  promontory  depressed  beneath  the 
anterior.  The  frontal  bone,  over  which  the  greatest 
squeeze  is  exerted,  is  pressed  beneath  the  parietal. 

To  make  the  difference  between  these  two  forms 
of  pelvis  clearer,  I  put  the  differences  in  a  table. 


FLAT  PELVIS. 

Incarceration    of   gravid   uterus 

common. 
Obliquity  of  uterus  common. 
Pendulous  belly  common. 
Transverse     presentations     and 

footling  presentations  common. 
Premature  rupture  of  membranes 

common. 
Head  usually  lying  transverse. 
Posterior  position  of  occiput  not 

specially  unfavourable. 
Brow  and  face  positions  common. 
Obliquity  of  Naegele  the  rule. 
Obstruction  at  brim  only. 

Small  caput  succedaneum. 
Little     oedema    of    vagina    and 

vulva. 
Dinting  of  cranial  bones  common 

and  moulding  slight. 


SMALL  ROUND   PELVIS. 

Incarceration   of   gravid    uterus 

not  specially  common. 
Obliquity  of  uterus  not  common. 
Pendulous  belly  not  common. 
Transverse  and  footling  presenta- 
tions not  common. 
Premature  rupture  of  membranes 

not  common. 
Head  usually  in  oblique  diameter. 
Posterior  position  of  occiput  very 

unfavourable. 
Brow  and  faee  positions  common. 
Obliquity  of  Naegele  rare. 
Obstruction    throughout    pelvic 

cavity. 
Great  caput  succedaneum. 
Great    oedema    of     vagina     and 

vulva. 
Dinting  of  cranial   bones   rare  ; 

moulding  great. 


I  may  complete  the  contrast  by  anticipating  the 
contents  of  the  next  chapter,  and  place  opposite  to 
one  another  the  different  treatment  of  each  form. 


FLAT   PELVIS. 

Turning,  if  passages  fully  dilated, 
the  best  treatment. 


SMALL   ROUND   PELVIS. 

Forceps     the     best     treatment. 
Turning  not  advantageous. 


*93 


CHAPTER  XVL 

TREATMENT  OP  LABOUR  WITH  CONTRACTED  PELTI8. 

In  this  chapter,  as  in  the  preceding  ones,  I  refer  only 
to  the  common  forms  of  contracted  pelvis :  the  flat 
pelvis,  the  rickety  pelvis,  and  the  small  round  pelvis. 

Flattened  Pelvis. 

Classification  according  to  degree  of  con- 
traction.— From  the  point  of  view  of  treatment* 
cases  of  flat,  rickety  or  non-rickety  pelvis  may  be 
roughly  divided  into  three  classes  : — 

1.  Those  in  which  a  full-time  child  cannot 
pass  through  the  pelvis.  This  includes  all 
cases  in  which  the  obstetrical  conjugate  is 
not  more  than  two  inches. 

2.  Those  in  which  a  full-time  child  cannot 
pass  living  through  the  pelvis.  This 
includes  all  cases  in  which  the  conjugate 
is  more  than  two  inches,  but  less  than 
three. 

3.  Those  in  which  it  is  possible  for  a  living 
child  to  traverse  the  pelvis  ;  cases  in  which 
the  obstetric  conjugate  is  at  least  three 
inches. 

This  is  only  a  rough  division.  It  holds  good  of 
the  majority  of  cases,  but  not  of  all,  for  the  following 
reasons  : — 

Why  only  approximate.— The  difficulty  of 
labour  depends  not  simply  on  the  size  of  the  pelvis, 
but  on  the  size  of  the  child  and  the  degree  of  ossifica- 
tion of  the  child's  head.  The  treatment  of  labour 
depends  also  upon  the  position  of  the  child,  the  way 
in  which  the   uterus   acts,    the   time   at   which   the 

»— 36 


194  Difficult  Labour. 

membranes  rupture,  and  other  features  of  the  course 
of  labour.  Remember  also  that  the  pelvis  cannot  be 
measured  during  life  with  greater  exactness  than  to 
within  a  quarter  of  an  inch.  Bearing  these  things  in 
mind,  you  will  see  that  rules  of  treatment  based  on 
the  length  of  the  conjugate  must  have  many  exceptions. 
Still,  the  size  of  the  pelvis  can  be  ascertained  with 
greater  approach  to  correctness  than  the  size  of  the 
child,  ;  and  we  do  not  go  far  wrong  in  assuming  that 
the  child  is  of  average  size  and  weight,  and  that  the 
degree  of  ossification  of  its  head  is  also  average ;  for 
wide  deviations  from  the  average  are  unusual.  The 
events  of  labour  cannot  be  predicted  beforehand. 
Therefore,  the  size  of  the  conjugate,  although  not  the 
sole  factor  which  determines  the  difficulty  of  delivery, 
is  yet  the  surest  basis  from  which  to  forecast  it. 

A  patient  with  contracted  pelvis  may  (1)  ask 
your  advice  during  pregnancy,  or  (2)  she  may  not 
suspect  the  deformity,  and  it  may  only  be  discovered 
when  labour  has  begun  at  term.  Consider  first  the 
former  case. 

Premature  labour. — It  is  better  to  prevent 
difficulty  than  to  have  to  treat  it.  Difficult  labour 
with  contracted  pelvis  is  prevented  by  inducing  pre- 
mature labour.  The  greater  the  contraction  the 
earlier  must  the  uterus  be  emptied  if  difficulty  is  to 
be  avoided.  This  is  the  view  you  will  take  if  you 
consider  solely  what  is  best  for  the  mother's  life  and 
physical  health. 

Alternatives    in   great    contraction.  —  The 

child  cannot  be  born  and  survive  before  the  end 
of  the  twenty-eighth  week  of  pregnancy.  The 
head  of  the  child  born  at  the  twenty-eighth  week 
of  pregnancy  cannot  pass  through  a  pelvis  having 
a  smaller  conjugate  diameter  than  two  inches  and 
three  quarters.  Hence  in  a  pelvis  so  small  as 
this,  your  choice,  or  rather  that  of  the  patient^ 
lies  between  the  induction  of  abortion  as  early 
as  possible,  and  deliberately  allowing  the  preg- 
nancy to  go  on  to  full  term  in  order  that  the  patient 


Induction  of  Premature  Labour.      195 

may  be  delivered  of  a  living  child  by  an  operation, 
either  symphysiotomy  or  Caesarian  section.  I  post- 
pone for  the  present  the  consideration  of  what  we  can 
do  when  it  is  the  wish  of  a  patient  with  pelvic  con- 
traction to  have  a  strong  and  healthy  living  child, 
and  consider  first  the  case  of  a  patient  who  only 
wants  to  get  safely  through  her  labour,  and  to  be  up 
again  as  soon  as  possible  after  it. 

Choice  of  time  for  induction  in  moderate 

contraction. — If  the  conjugate  diameter  be  two  inches 
and  three  quarters,  or  more,  and  the  transverse 
diameters  of  the  pelvis  not  so  shortened  that  you 
can  perceive  the  shortening,  a  living  child  may  be  de- 
livered if  labour  is  induced  prematurely.  The  earlier 
labour  is  induced  the  easier  will  be  the  labour,  and 
therefore  the  better  for  the  mother,  and  the  better 
the  prospect  of  the  child  being  born  alive  :  but  the 
greater  will  be  the  difficulty  of  rearing  the  child. 
Hence  the  selection  of  the  date  at  which  labour  shall 
be  induced  is  a  compromise  between  these  two 
difficulties  : — (1)  that  of  delivering  the  child  alive,  (2) 
that  of  rearing  it. 

Taking  the  conjugate  diameter  as  the  guide,  the 
following  are  about  the  dates  at  which  labour  may  be 
induced  in  different  degrees  of  deformity  : — 

Obstetrical  conjugate,  2|  inches  ...  28th  week. 
„  „  3        „      ...  30th     „ 

h  n  3i      »      -..32nd    „ 

„  „  3tj      „      ...  36th     „ 

But  do  not  forget  that  the  pelvis  is  only  one 
factor :  the  size  of  the  child  is  quite  as  important. 
The  date  above  given  is  that  at  which  the  patient 
should  be  told  to  be  prepared  to  have  labour  in- 
duced. Tell  her  to  let  you  examine  the  abdomen 
a  fortnight  before  the  date  assigned.  If  you  find 
the  child's  head  is  above  the  brim,  and  is  so  large 
that  you  cannot  press  it  down  into  the  brim,  bring 
on  labour  at  once,  without  waiting  for  the  pre- 
arranged time.      If,  on   the   other   hand,  when    the 


196  Difficult  Labour. 

appointed  time  comes  you  find  that  the  child  is 
small,  and  that  the  head  is  engaged  in  the  brim, 
or  that  you  can  easily  press  it  into  the  brim,  let  the 
pregnancy  go  on  for  another  fortnight,  and  then  ex- 
amine again.  If  you  find  that  the  head  is  not  pre- 
senting, alter  the  position  of  the  child  by  external 
manipulation  so  as  to  get  the  head  over  the  brim. 
If  the  head  is  near  the  top  of  the  uterus  and  there 
is  so  little  liquor  amnii  that  you  cannot  bring  it  down 
over  the  brim,  you  must  be  content  with  getting  the 
breech  into  the  brim  and  inducing  labour  at  the  time 
pointed  out  by  the  size  of  the  pelvis. 

The  methods  of  inducing  labour  are  described  in 
chapter  xxx. 

Labour  at  Term. 

But  you  will  not  always  have  the  opportunity  of 
preventing  difficulty.  You  may  not  be  called  till  the 
pregnancy  has  gone  to  term  and  labour  has  begun. 

Importance  of  pelvimetry  and  abdominal 
examination. — The  first  essential  to  proper  treatment 
is  an  early  diagnosis  of  (1)  the  size  of  the  pelvis,  and 
(2)  the  size  of  the  child.  Not  to  find  out  the  need  for 
Caesarian  section  until  the  child  has  been  destroyed, 
the  mother's  tissues  have  been  bruised  and  torn  and  her 
strength  has  been  exhausted  by  protracted  ineffectual 
labour  and  vain  attempts  to  deliver,  is  a  disgrace  to  the 
accoucheur  in  attendance,  for  such  extreme  deformity 
should  be  recognised  at  once.  It  is  not  quite  so  dis- 
creditable, but  still  a  thing  to  be  ashamed  of,  only  to 
discover  that  craniotomy  is  necessary  by  the  failure  of 
protracted  trials  of  other  modes  of  delivery. 

When  you  are  called  to  a  case  of  labour  in  which 
you  suspect  pelvic  contraction,  (1)  measure  the  pelvis, 
(2)  observe  the  effect  of  the  pains,  (3)  examine  the 
belly  to  find  out  (a)  the  size  of  the  child,  and  (b)  how 
far  you  can  press  it  down  with  your  hands  into  the 
pelvic  brim. 

Cases  in  which  Caesarian  section  is 
necessary. — The  question  of  treatment  is  simplest  in 


Caesarian  Sect io if.  197 

the  higher  degree  of  contraction.  An  expert  operator, 
with  good  instruments,  can  deliver  a  child  at  full 
term  through  a  rickety  pelvis  of  which  the  conjugate 
diameter  measures  two  inches.  If  smaller  than  this, 
delivery  by  the  vagina  is  impossible,  and  ought  not  to 
be  attempted.  Caesarian  section  is  the  only  mode  of 
delivery.  It  is  true  that  in  the  past,  when  Caesarian 
section  was  terribly  dangerous,  expert  handlers  of  the 
cranioclast,  vertebral  hook,  crotchet,  and  scissors, 
have  broken  up  and  extracted  a  child  through  a  pelvis 
with  a  conjugate  a  trifle  less  than  two  inches;  but 
such  operations  are  long  and  difficult,  and  entail  a 
risk  to  the  mother  as  great  as  that  now  involved  in 
Caesarian  section.  There  is  no  longer  occasion  for 
such  operations. 

The  rickety  pelvis  is  practically  the  only  one  met 
with  in  English  practice  which  presents  this  high 
degree  of  deformity.  Osteo-malacia  may  contract  the 
pelvis  even  more  than  rickets;  but  it  is  very  rare 
in  England,  and  if  the  disease  is  advancing,  the  bones 
will  be  soft,  so  that  the  pelvis  can  be  forced  open  with 
the  hand.  The  pelvis  has  been  thus  opened  up  so 
that  a  living  child  has  been  delivered  through  it. 
The  space  may  be  narrowed  as  a  result  of  fracture  of 
the  pelvic  bones,  or  from  tumour;  but  these  are  also 
rare. 

Cases  for  Caesarian  section  or  craniotomy. — 

If  the  conjugate  measures  above  two  inches,  and  the 
transverse  diameters  are  not  greatly  shortened,  the 
child  can  be  extracted  by  craniotomy.  If  it  measures 
less  than  three  inches,  the  child  cannot  be  born  alive 
(unless  it  be  very  small),  and  therefore  craniotomy 
should  be  performed  as  soon  as  the  os  uteri  will 
admit  the  hand,  without  injuring  the  mother  by 
attempts  at  delivery  in  other  ways.  Craniotomy  may 
be  required  when  the  conjugate  is  more  than  three 
inches,  but  in  such  cases  the  necessity  for  it  will  be 
revealed  in  the  course  of  labour. 

Craniotomy.—  The  smaller  the  pelvis  the  more 
difficult  is  craniotomy.     Statistics  nevertheless  show 


198  Difficult  Labour. 

that  fatal  results  more  often  follow  craniotomy  in  the 
lesser  degrees  of  contracted  pelvis.  This  is  because 
in  such  cases  craniotomy  is  often  postponed  until 
serious  damage  has  been  done  either  by  leaving  the 
case  too  long  to  nature,  or  by  ineffectual  attempts  at 
delivery  by  other  means.  The  mortality  of  craniotomy 
skilfully  done  at  the  proper  time  is  not  greater  than 
that  of  natural  labour. 

Caesarian  section  v.  craniotomy. — The  mor- 
tality of  Caesarian  section,  done  at  the  proper  time, 
in  suitable  places,  and  by  skilled  operators,  has  now 
been  reduced  to  about  8  per  cent.  *  Therefore,  in  cases 
in  which  the  pelvis  will  not  allow  the  birth  of  a  living 
child,  you  may  properly  propose  Caesarian  section  as 
an  alternative  to  craniotomy.  In  favour  of  craniotomy 
the  sole  argument  is  that  its  danger  to  the  mother  is  not 
greater  than  that  of  natural  labour.  Against  it  is  the 
fact  that  this  risk,  or  that  of  abortion,  together  with 
all  the  discomforts  of  pregnancy,  may  recur  again  and 
again ;  and  that  the  patient  will  never  have  the 
happiness  of  motherhood.  In  favour  of  Caesarian 
section  is  the  almost  certain  hope  of  a  strong,  healthy, 
living  child;  and  that  during  the  operation  the  patient 
can  be  sterilised,  so  that  the  discomforts  of  pregnancy 
and  the  risk  of  operation  will  not  recur.  Against 
Caesarian  section  is  its  danger  to  the  mother ;  nothing 
else.  The  facts  must  be  put  to  the  mother,  who  must 
decide.  The  conditions  on  which  the  danger  depends 
are  described  in  chapter  xxvm. 

Symphysiotomy. — Within  the  last  few  years  a 
method  has  been  perfected  by  which  in  pelves  having 
a  conjugate  diameter  of  three  inches  or  more,  you 
can  promise  the  patient,  at  the  cost  of  trifling  in- 
crease of  risk  and  inconvenience,  a  living  child  of 
average  size.  This  is  the  operation  of  symphysiotomy. 
Even  in  a  pelvis  having  a  conjugate  of  only  two 
inches  and  three  quarters,  you  can  do  so  by  combin- 
ing symphysiotomy  with  the  induction  of  labour 
shortly  before  full  term,  if  necessary.     The  date  must 

*  See  Muuro  Kerr,  Obst.  Soc.  Trans.,  vol.  xlvi.   1904,  p.  310- 


SYMPHYSIOTOMy.  I99 

be  fixed  by  estimating  the  relative  size  of  the  head 
and  the  pelvis.  By  symphysiotomy  you  add  half  an 
inch  to  the  conjugate  diameter,  as  well  as  slightly 
widening  the  transverse  measurements.  If  the 
greatest  diameter  of  the  foetal  head  exceeds  not  the 
size  of  the  conjugate  by  more  than  half  an  inch,  you 
can  deliver  by  symphysiotomy.  If  the  head  presents 
not,  you  can  only  roughly  guess  its  size  from  the 
measurements  of  the  belly.  If  the  greatest  girth  is 
not  more  than  36  inches,  and  the  distance  from  the 
pubes  to  the  top  of  the  uterus,  measured  over  the 
convexity,  is  not  more  than  13  inches,  you  may 
safely  conclude  that  the  child  is  not  larger  than  the 
average.  If  they  are  less  than  the  figures  given,  the 
child  is  small.  If  larger,  then  you  have  to  find  out 
whether  the  belly  is  big  from  fat,  from  an  excess  of 
liquor  arnnii,  or  because  the  child  is  big.  This  task 
is  difficult.  You  can  in  these  circumstances  only 
guess  at  the  size  of  the  child,  and  you  must  be 
cautious  in  prognosis.  I  shall  describe  symphysiotomy 
in  a  subsequent  chapter. 

Slighter  degrees  of  contraction.— Assuming 

that  labour  has  come  on  at  full  term,  and  that  the 
deformity  is  not  so  great  as  to  prevent  the  passage  of 
a  child,  take  greater  care  than  usual  to  prevent  prema- 
ture rupture  of  the  membranes.  They  will  very 
likely  break  too  soon.  Whether  they  do  or  not  will 
depend  upon  (a)  their  strength  and  (b)  the  pressure 
put  upon  them.  Over  (a)  their  strength  you  have  no 
control.  But  (6)  you  can  do  something  to  prevent  early 
rupture  by  keeping  the  patient  on  her  side,  so  that  the 
weight  of  the  liquor  amnii  may  not  help  the  uterine 
contractions  to  burst  the  membranes ;  by  telling  the 
patient  to  avoid  straining ;  and  by  being  exceedingly 
careful,  in  every  examination  you  make,  in  no  way  to 
injure,  or  increase  the  tension  of,  the  membranes. 

Do  all  you  can  to  favour  the  entry  of  the  vertex. 
With  a  flat  pelvis  there  is  a  tendency  for  the  head  to 
present  in  an  unfavourable  position — with  the  face, 
or  the  brow.     There  is  also  a  tendency  to  displacement 


200  Difficult  Labour. 

of  the  uterine  axis,  viz.  pendulous  belly,  or  great 
obliquity  of  the  uterus ;  and  these  displacements 
favour  abnormal  presentations.  You  will  promote 
entry  of  the  head  in  a  good  position  by  getting  the 
long  axis  of  the  uterus  to  coincide  with  that  of  the 
pelvic  brim.  If  there  be  pendulous  belly,  apply  a 
firm  binder  while  the  patient  is  on  her  back.  If 
there  be  great  lateral  obliquity,  bid  the  patient  lie  on 
the  side  opposite  to  that  towards  which  the  fundus 
uteri  is  deviated.  If  the  position  of  the  child  is  un- 
favourable, try  to  correct  it  by  external  manipula- 
tion. 

Watch  the  pains  with  greater  care  than  usual.  As 
there  may  be  difficulty,  it  is  most  necessary  that  the 
patient's  nervous  energy  should  be  preserved.  If  the 
patient  presents  signs  of  great  fatigue  before  the  time 
for  delivery  has  come,  give  opium,  so  that  she  may 
rest. 

If  the  disproportion  is  so  great  that  natural 
delivery  cannot  take  place,  and  help  is  not  given, 
either  the  uterus  will  pass  into  a  state  of  tonic 
contraction,  and  the  patient  die  undelivered ;  or 
rupture  of  the  uterus  or  vagina  may  take  place ; 
or  if  at  length  the  uterine  action  succeeds  in  forc- 
ing a  full-sized  child  through  a  contracted  brim, 
sloughing  of  the  soft  tissues  may  take  place.  The 
mechanism  of  these  two  lfttter  events  needs  further 
consideration. 

Nipping  in  first  Stage. — The  membranes  ought 
not  to  rupture  until  the  os  is  big  enough  to  admit  the 
hand.  If  the  membranes  rupture  prematurely,  the 
head  cannot  come  down  into  the  cervix  to  dilate  it 
until  the  uterus  has  forced  a  large  part  of  the  head 
past  the  brim ;  and  if  the  disproportion  be  great,  it 
will  not  come  into  the  cervix  at  all.  If  the  uterine 
action  is  violent,  the  head,  being  forced  down  upon 
the  sacrum  and  pubis,  may  so  nip  the  cervix  between 
it  and  the  pelvic  bones  that  the  contractions  of  the 
longitudinal  fibres  cannot  pull  the  cervix  up.  If  the 
labour  is  allowed  to  continue  without  treatment,  the 


Nipping. 


20I 


°?  -3 


continued  pressure  may  kill  the 
tissues  compressed,  and  then 
after  delivery  the  crushed  tis- 
sues slough,  so  that  a  vesical 
fistula  is  the  result  in  front, 
and  a  hole  in  the  cervix  open- 
ing into  the  peritoneum  be- 
hind. This  latter  injury,  if 
septic  infection  has  not  taken 
place,  is  soon  closed  by  adhe- 
sive inflammation. 

Nipping  in  second  stage. 

— But  the  pains  during  the 
first  stage  of  labour  may  be 
strong  enough  to  pull  open  the 
cervix,  and  yet  not  so  frequent 
and  prolonged  as  to  nip  the 
cervix  strongly  enough  to 
damage  it;  and  if  this  be  the 
case  the  cervix  will  not  be 
injured  during  its  dilatation. 
Then  the  pains  of  the  second 
stage  will  compress  the  vagina 
between  the  head  and  the  sym- 
physis, and  this  pressure  may 
kill  the  part  of  the  vesico- 
vaginal wall  subjected  to  it, 
and  a  vesico- vaginal  fistula  will 
result. 

Rupture  of  uterus.— If 

the  pains  are  very  strong  and 
follow  each  other  quickly  in  the 
first  stage  of  labour  (especially 
if  ergot  has  been  given),  the 
cervix  may  be  nipped  and  held 
fast  between  the  head  and  the 
pelvis,  while  the  upper  part  of 
the  uterine  body  goes  on  con- 
tracting and  the  lower  segment 
stretching;.   As  the  cervix  cannot 


202 


Difficult  Labour. 


be  pulled  up,  the  part  of  it  above  the  part  nipped 
is  stretched  immoderately,  and  may  give  way,  and 
rupture  of  the  uterus  takes  place  (Fig.  83). 

Rupture  Of  vagina.— If  after  the  cervix  has 
been  pulled  up  over  the  head  the  pains  become  very 
strong  and  frequent,  or  continuous,  from  ergot  having 
been  given,  and  the  obstruction  is  insurmountable, 
then,  as  the  uterus  pulls  the  cervix  up,  the  vagina 


Fig.  84.— Showing  what  is  meant  by  "Pendulous  Belly."  (After R.  Barnes.) 

A  e,  Normal  axis  of  uterus  and  child ;  b  f.  axis  of  uterus  and  child  with 
pendulous  belly;  s,  symphysis  pubis;  CD,  line  indicating  path  of  foetal  head 
round  pubes. 

will  be  stretched,  and  thus  rupture  of  tlie  vagina 
may  happen. 

From  pendulous  belly.— If  pendulous  belly  is 

present,  the  hanging  forward  of  the  uterus  may  so 
stretch  the  posterior  vaginal  wall  over  the  child's 
head  that  this  may  rupture,  even  though  the  pains 
are  not  vigorous,  nor  the  pelvis  so  contracted  as  to 
prevent  the  advance  of  the  child.  This  is  an  addi- 
tional reason  for  correcting  this  abnormal  position  of 
the  uterus  (Fig.  84). 


Artificial  Dilatation  of  the  Cervix.  203 

Prevention. — These  accidents  ought  not  to  be 
allowed  to  happen.  If  the  bag  of  membranes 
ruptures  prematurely,  either  (1)  the  child's  head  will 
come  down  into  the  cervix  and  put  the  rim  of  the  os 
uteri  on  the  stretch,  (2)  or  it  will  not.  If  (1)  it  does, 
it  may  be  inferred  that  the  disproportion  between  the 
child  and  the  pelvis  is  not  very  great,  and  the  labour 
may  be  left  to  take  its  course. 

Artificial  dilatation  of  the  cervix. — If  (2)  the 

disproportion  between  the  head  and  the  pelvis  is  so 
great  that  the  head  does  not  come  into  the  cervix  to 
stretch  it  open,  then  the  best  treatment  is  to  dilate  it 
artificially.  The  os,  though  not  fully  dilated,  may  be 
partly,  and  may  be  thin,  soft,  and  dilatable.  If  so, 
and  if  the  head  is  engaged  in  the  brim  in  a  good 
position,  the  cervix  will  probably  dilate  quickly  when 
the  head  is  pulled  down  into  it  with  forceps.  If  the 
os  is  too  small  for  forceps  to  be  applied,  or  if  the  head 
is  not  in  a  good  position,  or  not  presenting,  then  the 
best  treatment  will  be  to  replace  the  bag  of 
membranes  by  an  artificial  dilator.  The  best  is  the 
water-bag  of  Champetier  de  Ribes.  With  this  the 
cervix  is  dilated  to  the  full  extent  by  water  pres- 
sure alone.  (The  use  of  this  instrument  is  described 
in  the  chapter  on  Premature  Labour.)  I  believe 
that  it  will  be  found  of  great  service  in  these  cases ; 
it  is  possible  that  further  experience  may  show  some 
drawbacks  to  its  utility,  though  at  present  I  know 
of  none. 

When  the  cervix  is  fully  dilated  the  state  of 
things  can  be  made  out  more  closely  than  before. 
Measure  the  pelvis,  if  you  have  not  already  done  so, 
or  if  you  are  in  douK  as  to  the  correctness  of  your 
internal  measurements.  Examine  the  abdomen,  and 
if  the  head  present  see  how  far  above  the  pelvic  brim 
its  greatest  diameter  is  lying,  and  how  far  it  can  be 
pressed  down  into  the  brim  ;  and  ascertain  accurately 
its  position.     Listen  also  for  the  foetal  heart. 

Indications  for  immediate  craniotomy.— The 

patient's  circumstances  or  wishes  may  prevent  either 


204  Difficult  Labour. 

premature  labour  or  symphysiotomy.  In  that  case 
you  must  act  as  if  these  resources  existed  not.  The 
advice  which  follows  applies  to  cases  in  such  circum- 
stances. 

If  you  find  that  the  size  of  the  abdomen  is 
consistent  with  the  patient's  belief  that  she  has 
reached  term ;  that  the  greatest  diameter  of  the 
head  is  high  above  the  pelvic  inlet,  and  cannot  at 
all  be  pressed  down  into  the  pelvis ;  and  that  the 
conjugate  diameter  is  less  than  three  inches,  per- 
forate at  once. 

If  you  are  not  called  to  the  case  until  tonic 
contraction  of  the  uterus  has  set  in,  or  if  ergot  has 
been  given,  and  you  find  that  in  spite  of  continued 
uterine  action  the  greatest  diameter  of  the  head  is 
above  the  brim,  and  that  on  abdominal  examina- 
tion the  fetal  heart  is  not  to  be  heard,  then,  what- 
ever the  degree  of  narrowing  may  be,  perforate  at 
once. 

Indications  for  forceps. — If  the  conjugate  is 
three  inches  or  more,  the  fcetal  heart  is  audible, 
and  uterine  contractions  are  present,  examine  care- 
fully the  position  of  the  head.  If  it  is  lying  with 
its  long  diameter  transverse,  the  anterior  fontanelle 
as  low  down  as  the  posterior,  and  the  sagittal 
suture  nearer  the  promontory  than  the  symphysis 
but  not  less  than  three-quarters  of  an  inch  from  the 
promontory,  you  will  probably  find  that  the  greatest 
diameter  of  the  head  is  not  high  above  the  brim. 
The  position  of  the  head  is  here  as  favourable  as 
it  can  be,  and  you  will  probably  find  delivery  with 
forceps  easy. 

Most  favourable  position  of  head.— Litz- 
mann  pointed  out,  as  an  induction  from  clinical 
experience,  that  when  the  sagittal  suture  is  nearer 
the  promontory  than  the  symphysis,  and  not  less 
than  three-quarters  of  an  inch  from  the  former, 
forceps  delivery  was  generally  easy.  Take  a  fcetal 
head  and  a  pair  of  callipers,  and  place  one  point 
about  an  inch  from  the  sagittal  suture,  and  the  other 


Forceps  and   Turning.  205 

at  the  opposite  end  of  the  diameter  of  the  foetal 
head  taken  through  this  point;  you  will  find  that 
this  subparietal-superparietal  diameter  is  about  the 
smallest  that  you  can  get.  (The  end  of  the  finger  is 
too  obtuse  to  get  quite  to  the  point  of  contact  be- 
tween head  and  sacrum,  so  that  a  sagittal  suture 
apparently  distant  only  three-quarters  of  an  inch 
from  the  promontory  is  really  a  little  farther  from  it.) 
The  fact  that  the  sagittal  suture  is  in  this  position  is 
thus  proof  that  the  head  is  entering  the  brim  with 
the  smallest  possible  diameter  opposed  to  the  conju- 
gate. If  in  such  a  case  you  use  forceps,  you  will  feel 
the  posterior  parietal  bone  slip  rather  suddenly  past 
the  promontory ;  and  after  this  has  happened  delivery 
will  be  easy. 

Indications  for  turning". — If,  instead  of  find- 
ing the  head  in  this  position,  you  find  that  it  is 
in  (a)  a  face  position ;  (b)  a  brow  position ;  (c)  that 
the  sagittal  suture  is  nearer  the  pubes  than  the 
promontory ;  or  (d)  that,  although  the  pelvis  is  not 
contracted  to  a  high  degree,  yet  the  head  is  so  large 
that  its  greatest  diameter  is  high  above  the  brim ;  or 
if  there  be  (e)  prolapse  of  cord  or  an  extremity ; 
then  (the  cervix  being  fully  dilated)  turn  and  bring 
down  a  foot. 

Comparison  between  forceps  and  turning". — 

The  choice  between  forceps  and  turning,  when  the 
head  is  in  a  favourable  position,  depends  mainly  upon 
the  extent  to  which  the  head  is  engaged  in  the  brim. 
If  it  is  so  far  engaged  in  the  brim  that  its  greatest 
diameter  is  felt  by  abdominal  examination  to  be  not 
high  above  the  brim,  forceps  is  indicated.  If  the 
greatest  diameter  is  high  above  the  brim  you  should 
make  it  your  aim  to  estimate  so  accurately  the 
relative  size  of  head  and  pelvis  as  to  judge  early  in 
the  case  whether  craniotomy  will  be  required  or  not, 
and  not  waste  time  and  do  damage  by  vain  attempts 
at  the  impossible. 

For  reasons  already  given  one  cannot  be  always 
certain   that    delivery   with    forceps    is    or    is   not 


ao6 


Difficult  Labour 


Fig 


by  Traction  with   Base  in 
advance.    (After  Gdldbin.) 

Dotted  lines,  a  a,  66,  normal  shape 
of  head ;  continuous  lines  1 1, 
2  2,  shape  of  head  altered  by 
traction,  base  in  advance. 


possible.  Extreme  cases,  in  which  it  is  plainly 
impossible,  can  and  ought  to  be  recognised  at  once ; 
but  in  the  slighter  degrees 
of  contraction  you  cannot 
say  that  forceps  delivery 
is  impossible  till  you  have 
tried.  If,  the  cervix  being 
fully  dilated,  the  head  is 
so  high  and  movable  that 
the  indications  for  forceps 
are  not  clear,  and  yet  it  is 
not  so  large  that  delivery 
of  the  child  alive  is  clear- 
ly impossible,  turn.  Cases 
i.-showing  change  in  in  which,  from  faulty  posi- 
Shape  of  Head  produced  tion  of  the  head,  there  is 
an  evident  advantage  in 
turning,  also  ought  to  be 
recognised  at  once. 

Statistical  comparisons 
between  the  results  of  forceps  and  turning  are 
not  worth  much.  Forceps 
delivery  may  need  hard 
pulling,  but  that  is  the 
only  difficulty  about  it. 
On  the  other  hand,  to  de- 
liver a  living  child  by 
turning  requires  consider- 
able skill.  The  right  mo- 
ment must  be  chosen,  viz. 
when  the  passages  are  di- 
lated, but  before  the  liquor 

amnii    has    Completely    run     Fig.  86.-Showing  Change  in  Shape 
,  ,i  ot  Head  produced  by  down. 

on ;  the  arms  must  be 
quickly  brought  down,  and 
the  head  promptly  de- 
livered; and  promptly 
means  skilfully.  Hence  an 
unskilful  accoucheur  will  get  better  results  with  for- 
ceps than  with  turning,  for  if  turning  is  done  too 


ward  Pressure  with  Vertex  in 
advance.    (After  Galabin.) 

Dotted  lines,  aa.bb.ee,  normal  shape 
of  head ;  continuous  lines,  1 1, 2  2, 
shape  of  head  altered  by  pressure 
from  above 


Advantages  of   Turning.  207 

early  or  too  late,  and  extraction  bungled,  the  results 
will  be  bad.  Some  statistics  show  that  the  propor- 
tion of  children  delivered  alive  by  forceps  is  larger 
than  that  of  children  delivered  by  turning.  The 
mortality  to  the  children  delivered  by  turning  arises 
not  in  turning,  but  in  extraction. 

Advantages  in  turning. — The  advantage  of 

turning  is  that  when  the  head  comes  through  the 
pelvis  base  first,  the  parietal  bones  are  pressed  to- 
gether from  below  upwards  (Fig.  85).  Such  pressure 
tends  to  flatten  them,  to  make  their  curve  less  so 
that  they  approach  one  another  at  a  less  obtuse  angle, 
and  to  make  the  vertical  measurement  of  the  skull 
greater  and  the  transverse  less.  If  the  vertex  pre- 
sents, the  pressure  of  the  resistance  on  the  vertex 
tends  to  prevent  lengthening  of  the  vertical"  diameters 
of  the  head,  and  therefore  to  prevent  the  pressing 
together  of  the  parietal  bones  and  the  shortening  of 
the  transverse  diameters  (Fig.  86).  When  the 
head  presents  in  a  favourable  position  this  ad- 
vantage of  turning  is  slight,  and  is  counterbalanced 
by  the  risk  to  the  mother  in  turning  and  to  the  child 
in  extraction.  When  the  head  presents  in  an 
unfavourable  position  there  is  a  great  advantage  in 
turning. 

Briefly  summed  up,  the  principles  of  treatment 
are  (in  cases  of  flat  pelvis  in  which  the  head  does  not 
enter  the  brim)  these :  Estimate  the  relative  size  of 
the  head  and  pelvis.  Artificially  hasten  dilatation 
if  necessary.  If  the  head  is  so  large  that  it  plainly 
cannot  enter  the  brim,  perforate  at  once.  If  the 
head  is  engaged  in  the  brim  in  the  most  favour- 
able position  (that  is,  with  the  sagittal  suture 
running  transversely  and  distant  about  three- 
quarters  of  an  inch  from  the  sacral  promontory),  use 
forceps.  If  the  head  is  in  an  unfavourable  posi- 
tion, wait  till  the  cervix  is  fully  dilated,  and  then 
turn  and  deliver.  If  by  forceps,  or  pulling  on  the 
after-coming  head,  you  cannot  get  it  through,  per- 
forate. 


208  Difficult  Labour. 

The  Small  Round  Pelvis. 

The  difficulty  in  delivery  that  comes  from  the 
pelvis  being  of  the  small  round  kind,  and  that  from 
the  child's  head  being  too  large,  are  practically  the 
same. 

Premature  labour.— Difficulty  may  be  pre- 
vented by  inducing  labour  prematurely.  It  has  been 
long  recognised  as  sound  practice  to  induce  labour 
prematurely  in  a  patient  who  has  had  difficult  labours 
due  to  the  children  being  too  big. 

In  this  form  of  pelvic  contraction  it  is  more  difficult 
to  estimate  the  proper  time  at  which  labour  should  be 
brought  on,  because  the  diameter  which  we  can  most 
easily  measure,  the  diagonal  conjugate,  is  not,  as  in 
the  flat  pelvis,  the  key  to  the  probable  amount  of 
difficulty.  Moreover,  the  true  conjugate  cannot  so 
easily  be  estimated  from  the  diagonal  conjugate, 
because  the  sacral  promontory  is  higher  up  than  usual, 
and  therefore  the  deduction  to  be  made  in  order  to 
get  the  true  conjugate  is  greater.  And  the  difficulty 
depends,  not  only  on  the  conjugate,  but  on  the 
other  measurements  of  the  true  pelvis,  and  these  we 
cannot  measure  before  delivery.  For  these  reasons, 
a  date  for  premature  labour  deduced  from  the  length 
of  the  diagonal  conjugate  is  in  this  form  of  pelvis  not 
likely  to  prove  satisfactory. 

The  best  plan  is  to  instruct  the  patient  to  come 
for  examination  at  a  date  a  month  earlier  than  that 
to  which  you  think  she  may  safely  go,  and  then 
to  examine  the  abdomen,  so  as  to  judge  of  the  size  of 
the  child,  and  find  out  also  how  far  the  head  is 
engaged  in  the  brim,  or  how  far  and  how  easily  it  can 
be  pressed  into  the  brim.  If  the  child  is  small,  and 
the  head  is  engaged  in  the  brim  or  can  be  easily 
pressed  into  it,  tell  the  patient  to  come  again  in  a 
month  or  a  fortnight,  according  to  the  ease  with  which 
you  can  press  the  head  into  the  pelvis.  If  the  head 
is  not  presenting,  turn  the  child  by  external  manipu- 
lation and  get  the  head  over  the  brim.     Watch  the 


Small   Round  Pelvis.  209 

growth  of  the  child  by  successive  examinations,  and 
when  you  find  that  the  head,  though  engaged  in  the 
pelvic  brim,  is  not  very  movable  within  it,  induce 
labour  without  further  delay. 

First  Stage  Of  labour. — Leave  the  case  entirely 
to  nature.  Neither  mother  nor  child  will  suffer  from 
delay  while  the  liquor  amnii  is  retained  :  and  the  bag 
of  waters  will  dilate  the  cervix  better  than  anything 
else.  In  this  form  of  pelvis  there  is  no  special  ten- 
dency to  premature  rupture  of  membranes.  Ascer- 
tain carefully  the  position  of  the  child,  and  if  the 
back  is  behind,  turn  it  forwards ;  if  the  position  be 
transverse,  rectify  it. 

If  the  membranes  have  ruptured  before  the  os  is 
fully  dilated,  and  the  head  is  engaged  in  the  brim, 
pressing  down  into  the  cervix,  leave  the  case  to  nature. 
The  cervix  will  be  dilated  by  the  head  better  than  by 
anything  else.  Sustain  the  patient's  strength  by  food, 
and  her  nerve  force  by  procuring  sleep  if  necessary. 
It  is  very  unlikely  that  impaction  will  occur  before 
the  dilatation  of  the  cervix  is  complete. 

Second  Stage. — The  head  may  become  impacted 
in  the  pelvic  cavity.  Now  is  the  time  that  treatment 
is  required.  Impaction  means  that  the  head  is  stuck 
fast,  it  neither  advances  nor  recedes.  The  cervix  is 
usually  dilated  and  retracted  over  the  head  before 
impaction  takes  place  :  but  it  may  be  nipped  and  held 
down  between  the  impacted  head  and  the  pelvic  wall 
so  that  it  cannot  rise.  If  there  be  impaction  the  need 
for  treatment  is  urgent,  whether  the  cervix  is  dilated 
or  not.  If  the  head  is  left  impacted  a  great  caput 
succedaneum  will  form  and  oedema  of  the  vagina  and 
vulva  will  begin.  If  the  second  stage  has  lasted  two 
hours,  notwithstanding  strong  pains,  do  not  wait  for 
evidence  of  impaction,  but  give  help.  The  treatment 
is  to  apply  forceps  and  pull.  Pull  with  the  pains,  not 
between  them.  If  the  result  of  each  pull  is  to  make 
the  head  advance,  continue  to  pull  with  each  pain  till 
the  head  is  delivered.  If  the  pains  are  frequent  and 
your  pulling  has  no  effect,  auscultate  the  foetal  heart. 
-36 


2io  Difficult  Labour. 

If  you  cannot  hear  it,  perforate.  If  you  can  hear  it, 
and  the  cedenia  of  the  vulva  is  absent  or  slight,  con- 
tinue pulling  with  each  pain.  If  after  pulling  with 
each  pain  during,  say  an  hour,  you  have  not  moved 
the  head,  perforate,  whether  the  child  be  alive  or  dead. 
In  this  form  of  pelvis,  or  in  labour  with  a  large  child, 
there  is  nothing  gained  by  turning ;  therefore  do  not 
attempt  it. 


* 


CHAPTER  XVII. 

THE  BARE  FORMS  OF  CONTRACTED  PELVIS. 

The  kinds  of  contracted  pelvis  described  in  this 
chapter  are  so  rare  that  you  may  practise  midwifery 
for  years  without  meeting  one  of  them.  The  know- 
ledge we  have  of  their  obstetric  history  and  treatment 


A 

Fig.  87.— Diagram  of  the  generally-contracted  Flat  non-rickety  Pelvis. 

Black  line  normal  pelvis ;  dotted  line,  contracted  pelvis  ;  e,  sacral  concavity  a 
brim;  b  b, sacrum;  o  C, transverse  diameter;  d  d,  iho-pectineal  eminence 
a,  symphysis. 

is  based  on  compilations  of  very  few  cases  collected 
from  books.  No  obstetrician  has  in  his  life  seen  many 
cases  of  any  one  of  the  following  pelves. 

The  kinds  I  first  mention  are  usually  classed 
as  varieties  of  the  two  common  kinds  of  contracted 
pelvis — the  flat  and  the  small  round  ;  but  I  do  not 
think  that  any  useful  purpose  is  served  thereby. 
The  first  is  considered  a  variety  of  the  flat  pelvis, 
although  it  is  produced  in  quite  a  different  way. 

The  generally-contracted  flat  non-rickety 


212 


Difficult  Labour. 


pelvis. — A  generally-contracted  and  flattened  pelvis 
is  generally  rickety  ;  but  th«re  are  cases  presenting 
the  measurements  of  this  deformity  without  any  sign 

of  rickets.  These 
rare  pelves  differ 
from  the  rickety 
in  the  following 
way :  The  pro- 
montory of  the 
sacrum  is  high 
above  the  brim, 
and  its  lateral 
masses  are  small, 
as  in  the  gener- 
ally -  contracted 
pelvis  (Fig.  87). 
But  the  ilia  and 
the     ischia      are 

Fig.  88.— Diagram  of  Pelvic  Cavity  of  geneially-    small,  and   hence 
contracted  flat non- rickety  Pelvis.  .1  e    ay. 

,  .,  the  part   of   the 

A  b,  True  conjugate ;  a.  o,  diagonal :  0  d,  antero-         ,     *       .         „ 

posterior  diameter  of  outlet.  pelvic  ring  IOrm- 

ed  by  these  bones 
is  short ;  the  sacrum  is  thus  brought  nearer  to  the 
pubes  and  the  shape  of  the  pelvis  made  like  that  of  a 
flattened  pelvis  (Fig.  88). 

Etiology. — It  is  due  to  a  defect  in  development ; 
beyond  this  we  know  nothing. 

The  diagnosis  is  very  difficult.  Owing  to  the  high 
position  of  the  promontory  the  difference  between  the 
diagonal  and  true  conjugate  is  increased,  instead  of 
lessened,  as  in  the  flat  pelvis ;  and  this  may  lead 
to  the  degree  of  contraction  being  under-estimated. 

The  treatment  is  the  same  as  that  of  the  small 
rickety  pelvis. 

The  three  following  kinds  are  usually  described  as 
varieties  of  the  generally-contracted  pelvis. 

The  dwarf  S  pelvis. — This,  as  its  name  implies, 
is  met  with  in  dwarfs.  It  is  characterised  by  small- 
ness  in  size,  with  a  shape  like  that  of  the  healthy 
adult  pelvis  ;  and  by  abnormal  delay  of  union  between 


The  Small  Round  Rickety  Pelvis.      213 

the  three  bones  which  unite  to  form  the  innominate 
bone  (Fig.  89).  In  some  cases  the  sacral  promontory 
has  been  high  up,  and  the  lateral  masses  of  the  sacrum 
small,  as  in  the  sipall  round  pelvis. 

Cases  of  labour  with  the  dwarf's  pelvis  are  so  rare 
that  we  know  nothing  about  its  obstetric  history. 

Achondroplasia. — There  is  a  kind  of  dwarfing 
in  which   the  stature  is  small  because  the  arms  and 


Fig.  89.— Dwarf  s  Pelvis. 

legs  are  short  in  proportion  to  the  trunk.  This  is 
believed  to  be  the  result  when  a  subject  of  the  intra- 
uterine disease  to  which  Parrot  gave  the  name  of 
"  achondroplasia  "  is  born  alive  and  grows  up.  In 
these  dwarfs  the  pelvis  is  contracted,  but  we  cannot 
at  present  define  the  characteristic  shape  of  the  pelvis; 
for,  so  far  as  I  am  aware,  no  specimens  have  yet  been 
examined  after  death,  and  most  of  the  patients  ex- 
amined during  life  had  suffered  from  rickets  as  well.* 

The  small  round  rickety  pelvis. — The  un- 
known developmental  conditions  which  produce  the 
small  round  pelvis  do  not  protect  the  patient  from 
rickets.  If  a  patient  with  such  a  pelvis  has  rickets, 
and  the  rickety  changes  in  the  bones  are  only  slight, 
•  See  Lancet,  Dec.  23,  1893. 


214 


Difficult  Labour. 


the  pelvis  will  retain  its  general  shape,  but  the  signs 

of  rickets  will  be 
present.  The  con- 
jugate will  be 
only  slightly  di- 
minished, the 
lateral  walls  of 
the  pelvis  easily 
felt,  the  sacrum 
convex  from  side 
to  side,  the  epi- 
physeal ridges 
prominent.  I 
have  seen  one  case 
of  this  deformity. 
Its  obstetric 
££  '  history  and  treat- 

Fig.  90— Diagram   of  Cavity  of  Funnel-shaped  ment       are       the 
Pelvis  in  Sagittal  Plane.  same    as    that   of 

Continuous  line,  normal  pelvis;  dotted  line,  funnel-  {.],„  omoll  rnnnri 
shaped  pelvis ;  A  B,  true  conjugate ;  A c,  diagonal  LIic  wu*11  iuuliu 
conjugate;   O  D,  antero  -  posterior  diameter  of    pelvis  without 

signs  of  rickets. 

The  ftmnel-shaped  pelvis.— By  this  is  meant 

a  pelvis,  not  associated  with  any  change  in  the  spinal 
column,  whose  internal  diameters  diminish  from  the  in- 
let to  the  outlet.  Such  cases  are  exceedingly  rare.  Only 
two  have  been  carefully  measured.  The  transverse 
diameter  is  that  in  which  the  contraction  towards  the 
outlet  is  greatest.  These  pelves  have  been  further 
classified  according  to  whether  or  not,  and  to  what 
degree,  the  other  diameters  are  diminished  also  ;  but 
seeing  how  rare  such  pelves  are,  this  subdivision  seems 
premature.  The  essential  changes  seem  to  be  length 
and  narrowness  of  the  sacrum,  so  that  the  promontory 
is  higher  than  usual  above  the  brim,  and  the  difference 
between  the  diagonal  and  the  true  conjugate  is  in- 
creased, amounting  to  an  inch  or  more  (Figs.  90,  90a). 
Etiology. — Nothing  whatever  is  known  of  the 
cause,  beyond  that  it  is  a  developmental  abnormality. 
Theories  about  it  will  be  found  in  German  books. 


Funnel-shaped  Pelvis. 


215 


Diagnosis. — With  present  methods  of  examination 
this  pelvis  is  difficult  to  diagnose  during  pregnancy. 
It  is  usually  first  discovered  hy  the  difficulty  of 
delivery.  After  delivery  it  can  only  be  diagnosed, 
and  that  not  with  precision,  by  internal  examination 


1 


.'A 


sB 

a- 

b 

1 

1 
• 
1 

1 
1 
1 
1 
1 

• 
1 

> 
» 

1 

1 
• 

Fig.  90a.— Diagram  of  Cavity  of  Funnel-shaped  Pelvis  In  Coronal  Plane. 

Continuous  line,  normal  pelvis  ;  dotted  line,  funnel-shaped  pelvis ;  a  a,  iliac 
crests ;  b  b,  transverse  diameter  of  brim ;  0  0,  inner  surface  of  tubera  Ischii. 


with  the  whole  hand.  This  will  show  the  high 
position  of  the  promontory,  and  the  straightness  of 
the  sacrum.  The  abnormal  diminution  in  the  size  of 
the  transverse  diameter  may  then  be  suspected  ;  but 
exact  measurement  of  this  diameter  is  not  possible. 

Effect  on  labour. — The  funnel-shaped  pelvis  does 
not  prevent  the  entry  of  the  head  into  the  pelvis.  Its 
only  effect  on  labour  is  that  if  the  head  is  large  it  may 
be  arrested  in  the  pelvic  cavity  during  the  second  stage. 
This  arrest  takes  place  before  the  head  has  come  to 
press  upon  the  pelvic  floor,  and  therefore  before  the 
occiput  has  begun  to  turn  forwards.  The  effects  on  the 
soft  parts  are  the  same  as  in  the  generally  contracted 
pelvis.  The  head  may  be  marked  by  the  spines  or 
tuberosities  of  the  ischium. 

The  treatment  is  to  deliver  with  forceps,  and  if 
that  fail,  by  craniotomy.  If,  with  a  child  of  aver- 
age size,  presenting  with  the  vertex,  craniotomy  is 


2t6  Difficult  Labour. 

required,  labour  should  be  prematurely  induced  in 
subsequent  pregnancies. 

The  pseudo-osteomalacic  rickety  pelvis.— In 

this  pelvis,  although  the  softening  of  the  bones  is  due 
to   rickets,  the   deformity  produced   is  like  that   of 
osteo-malacia  (Fig.  91),  which  will  be  described  later. 
The  production  or  not  of  this  form  of  pelvis  depends 
on  (1)  the  amount  of  softening  of  the  bones,  and  (2) 


Fig.  91.— Psendo-osteomalacic  Rickety  Pelvis.    (Afler  Naegele.) 

whether  or  not  the  patient  stands  or  walks  much.  If 
the  bones  are  not  extremely  soft  and  the  patient  is  able 
to  stand  and  walk,  the  heads  of  the  femora,  reacting  to 
the  body  weight,  push  the  acetabula  upwards  and  thus 
move  them  outwards,  and  the  usual  kind  of  rickety 
pelvis  is  the  result.  If  the  patient  cannot  stand  or  walk, 
(a)  there  is  no  upward  pressure  of  the  femora  to  press 
the  acetabula  upwards  and  outwards,  and  (b)  if  in 
addition  the  bones  are  so  soft  as  to  yield  to  muscular 
action,  the  muscles  pull  the  ischia,  ilia,  and  pubic  bones 
towards  the  trochanters,  and  drive  the  necks  of  the 
femora  inwards,  thus  crumpling  inwards.the  acetabula. 
When  this  crumpling  of  the  os  innominatum  has 
gone  far  enough  to  bring  the  acetabula  within  the 
line  joining  the  sacro-iliac  sychondrosis  and  the  feet, 
then,   if   the  patient   stands   or   walks,   the    upward 


The  Skolio-rachitic  Pelvis. 


217 


pressure  of  the  femora  drives  the  acetabula  in  instead 
of  out,  and  thus  increases  the  deformity. 

One  of  the  most  characteristic  cases  of  this  type  of 
pelvis  was  described  by  Naegele,  and  the  subject  of  it 
did  not  attempt  to  walk  till  the  age  of  seven. 

The  obstetric  history  is  that  of  the  osteomalacic 
pelvis,  excepting   that  it  is   impossible   in  a  pelvis 


Fig.  92.— Skolio-rachitic  Pelvis.    (After  A.  Martin.) 

deformed  in  this  way  to  open  up  the  pelvis  with  the 
hand,  as  has  been  done  in  progressing  osteomalacia. 

The  skoliotic  pelvis. — Rickets  is  often  asso- 
ciated with  lateral  curvature  of  the  spine.  When  this 
is  so,  the  skoliotic  pelvis  is  produced  (Fig.  92).* 

The  effects  of  skoliosis  of  the  spine  on  the  pelvis 
depend  on  (1)  the  age  at  which  the  skoliosis  begins, 
and  (2)  whether  the  bones  are  softened  by  disease  or 
not.  Skoliosis  coming  on  after  the  pelvis  is  ossified, 
without  rickets,  does  not  produce  enough  pelvic 
deformity     to     be     obstetrically     appreciable.     But 

*  For  full  information  as  to  this  kind  of  pelvis  see  Champneys, 
St,  Bartholomew's  Hospital  Reports,  vol.  xviii.,  1882,  p.  190. 


2i8  Difficult  Labour. 

skoliosis  in  rickety  children  produces  important 
modifications  in  the  pelvic  deformity 

When  the  spine  is  laterally  curved,  the  body 
weight,  instead  of  falling  on  the  middle  of  the  sacrum, 
falls  on  one  side  of  it,  viz.  the  side  towards  which  the 
convexity  of  the  lumbar  curve  looks.  Hence  this  side 
of  the  sacrum  is  overweighted,  driven  down  more, 
and  brought  nearer  to  the  acetabulum  on  that  side. 
The  acetabulum  on  the  side  of  the  lumbar  convexity 
is  thus  brought  nearer  the  line  along  which  the  body 
weight  acts,  and  that  on  the  opposite  side  farther 
from  it.  The  pressure  of  the  femur  nearer  the  line  of 
the  downward  pressure  acts  to  greater  advantage 
upwards,  and  less  outwards ;  that  of  the  opposite  femtir 
to  greater  advantage  outwards,  and  less  upwards.  In 
consequence  of  the  former  pressure  the  acetabulum  on 
the  side  of  the  lumbar  convexity  is  pushed  up,  the 
ilium  between  it  and  the  sacrum  more  sharply  bent, 
the  sacro-cotyloid  diameter  shortened.  The  ischium 
on  that  side  is  pulled  out,  because  the  distance 
between  the  origin  and  insertion  of  the  muscles 
attached  to  it  is  increased  by  the  upward  movement 
of  the  femur.  The  increased  outward  pressure  on  the 
less  weighted  side  pulls  the  symphysis  pubis  over 
towards  that  side,  and  causes  the  wing  cf  the  ilium  to 
look  more  forward.  The  sacro-cotyloid  diameter  on 
this  side  is  greater  than  on  the  side  of  the  lumbar 
convexity  (Figs.  93,  93a). 

Diagnosis. — The  presence  of  lateral  curvature  of 
the  spine  in  a  rickety  subject  will  at  once  suggest 
that  the  pelvis,  if  the  skoliosis  is  of  early  date,  is  of 
the  skolio-rachitic  form.  The  fact  that  the  pelvis  is 
asymmetrical  can  be  exactly  noted  by  taking  the  same 
measurements  as  in  diagnosing  the  Naegele  pelvis 
(page  233).  But  the  only  measurements  really  valu- 
able, from  an  obstetrical  point  of  view,  are  the  in- 
ternal ones : .  the  conjugate,  and  the  right  and  left 
sacro-cotyloid  measurements.  All  these  ai-e  shortened, 
and  the  latter  measurements  are  unequal.  The 
prospect    of   safe   delivery   depends   on   the   size  of 


The  Skolio-rachitic  Pelvis.  219 

th©     larger     sacro-cotyloid      measurement.        These 


Pig.  98.— Diagram  of  Brim  of  Skolio-rachitic  Pelvis. 

Continuous  line,  normal  pelvis ;  dotted  line,  deformed  pelvis ;  b  b,  sacro-lliac 
synchondroses ;  b,  centre  of  sacrum  in  plane  of  brim ;  o  o,  transverse 
diameter ;  d  d,  pectineal  eminences ;  a,  symphysis  pubis, 

measurements  must  be  guessed  at  with  the  fingers, 
or  measured  with  the  whole  hand  in  the  pelvis. 

Treatment. — In  slight  cases,  natural  delivery  may 


Fig.  93a.— Diagram  of  Cavity  of  Skolio-rachitic  Pelvis. 

Continuous  line,  normal  pelvis;  dotted  line,  deformed  pelvis;  a  b,  true  con 
Jugate;  AC,  diagonal.conjugate;CD, antero-posterior  diameter  of  outlet. 


22o  Difficult  Labour. 

take  place,  and  the  treatment  is  that  of  the  flat  pelvis. 
When  the  smaller  sacro-cotyloid  is  below  two  inches 
and  a  half,  craniotomy  will  be  required,  unless  the 
child  be  very  small.  Below  this  the  choice  is  between 
craniotomy  and  Caesarian  section.  In  marked  cases 
the  latter  operation  is  usually  necessary.  Slight  cases 
are  not  common  enough  to  enable  rules  for  treatment 
to  be  laid  down  with  precision. 

Rickets  may  be  associated  with  both  angular  and 
lateral  curvature  of  the  spine;  and  when  these 
diseases  occur  with  rickets  in  early  life,  we  have  the 
kypho-skoliotic  pelvis.  To  understand  this,  it  is 
necessary  first  to  comprehend  the  production  of  the 
kyphotic  pelvis.   This  I  shall,  therefore,  next  describe. 

The  kyphotic  pelvis.  —  In  angular  curvature 
of  the  spine  the  upper  limb  of  the  angle  is  so  inclined 
forward  that  without  some  compensatory  change  the 
body  would  fall  forward.  When  the  angle  is  high  up, 
the  compensation  is  made  by  great  lordosis  of  the 
lumbar  spine,  and  no  effect  on  the  pelvis  is  produced. 
When  the  curvature  is  so  low  down  that  change  in 
the  curve  of  the  spine  below  it  is  not  enough  to 
compensate  for  the  change  in  the  incidence  of  pr&ssure 
produced  by  the  angle,  a  "change  in  the  inclination 
of  the  pelvis  takes  place,  and  this  change  in  the 
inclination  gradually  produces  change  in  shape. 

In  the  diagram  (Fig.  94),  c  G  represents  the  upper 
limb  of  the  kyphosis.  The  weight  of  the  upper  part  of 
the  body  acts  along  this  line,  in  the  direction  of  c  G I ; 
G  p  represents  the  lower  limb  of  the  angle  ;  p  is  the 
sacral  promontory ;  p  c  the  sacrum.  It  will  be  seen 
that  the  effect  of  the  pressure  is  to  drive  the  angle  of 
the  kyphosis  downwards  and  backwards,  and  thus  to 
pull  p  upwards  and  backwards.  The  direction  of  the 
pelvic  brim  is  changed,  so  that  its  plane  would,  if  its 
shape  were  unaltered,  form  a  less  angle  with  that  of 
the  horizon.  But  the  pull  on  the  sacral  promontory 
acting  continuously  for  years  gradually  makes  the 
curve  from  above  downwards  less,  raises  the  promon- 
tory above  the  level  of  the  brim,  and  lengthens  the 


Production  of  Kyphotic  Pelvis.         221 


conjugate  diameter  of  the  brim.  The  concavity  of 
the  sacrum  from 
side  to  side  is  in- 
creased, just  as  in 
rickets  it  is  chang- 
ed into  convexity; 
in  rickets  the 
bodies  of  the  ver- 
tebrae are  pushed 
down,  in  kyphosis 
pulled  up,  the  lat- 
eral masses  being 
in  either  case 
bound  by  liga- 
ments to  the  ossa 
innominata  (Fig. 
95).  The  tip  of 
the  sacrum  moves 
forward  as  the 
promontory  moves 
back,  so  that  it 
projects    into   the 

outlet  and  narrows  it  (Fig.  96).  The  base  of  the  sacrum 
pulls  with  it  the  sacro-iliac  synchondroses,  and  then  the 
shape  of  the  os  innominatum  is  altered,  although  this 
change  is  not  so  great  as  that  of  the  sacrum.  The 
curve  of  the  ilio-pectineal  line  is  not  so  sharp  (Fig.  97). 
The  most  important  change  of  the  ossa  innominata  is 
that  of  position.  The  lessened  inclination  of  the 
pelvis  causes  great  strain  on  the  ilio-femoral  liga- 
ments. These  pull  the  anterior  inferior  iliac  spines 
down  and  out,  and  so  rotate  the  ossa 
about  an  axis  running  from  before 
separate  the  ilia,  and  turn  in  the  ischia. 
outlet  is  contracted  transversely,  the 
diameter  at  the  inlet  slightly  widened,  the  conjugate 
much  lengthened.  The  degree  of  these  changes 
depends  on  how  low  down  the  kyphosis  is. 

Although   angular    curvature    of  the    spine  is   a 
common  disease,  yet  high  degrees  of  kyphotic  shape  of 


Fig.  94. — Diagram  illustrating  the  Production 
of  Kyphotic  Pelvis. 

a,  Angle  of  kyphosis ;  pp',  promontory  of  sacrum ; 
cc',  tip  of  sacrum. 


innominata 

backwards, 

Hence  the 

transverse 


222  Difficult  Labour. 

pelvis  are  rare,  because  they  only  occur  when  the  spina! 
disease  begins  early,  and  affects  the  spine  low  down 


95. — Kyphotic  Pelvis.     (After  Barbour.) 


The  diagnosis  is  not  difficult,  because  the  patient's 
short  stature  and  hump  back  suggest  examination  ol 
the  spine,  by  which  the  angular  curvature  is  detected. 
Then  the  pelvis  should  be  examined,  and  the  measure- 
ments of  the  outlet  taken  with  care.  Those  of  the 
brim  are  difficult  to  take  accurately,  and  as  they  are 
all  increased,  the  amount  of  increase  is  not  important 


The  Kyphotic  Pelvis. 


223 


Influence  on  labour. — The  course  of  labour  with 
the  kyphotic  pelvis  depends  on  the  degree  of  the 
deformity.  The  few  cases  that  have  been  accurately 
observed  make  our  knowledge  as  yet  not  so  exact  as 
it  will  be. 

In  consequence  of  the  convexity  of  the  lumbar 
spine  being  gone,  there  is  no  longer  the  corre- 
spondence between  the   convexity  of  the  spine  and 


Fig.  96.— Diagram  of  Cavity  of  Kyphotic  Pelvis  in  Sagittal  Plane. 

Continuous  line,  normal  pelvis;  dotted  line,  deformed  pelvis;  ab,  true  conju- 
gate ;  A  c,  diagonal  conjugate ;  0  D,  an t  ero-pos t erior  diameter  of  outlet. 


the  concavity  of  the  abdominal  aspect  of  the  child, 
which  is  the  chief  reason  why  the  back  of  the  child  is 
generally  in  front.  Hence  with  the  kyphotic  pelvis 
occipito-posterior  positions  are  proportionately  more 
frequent.  The  position  of  the  rectum  on  the  left  side 
makes  presentations  in  the  right  oblique  diameter 
more  frequent  than  those  in  the  left. 

The  turns  which  the  head  makes  in  its  passage 
through  the  pelvis  depend  on  the  degree  of  deformity 


224 


Difficult  Labour. 


If  the  contraction  of  the  outlet  is  so  slight  that  the 
head  can  pass  through  it,  the  result  is,  that  instead  of 
the  occiput  waiting,  as  it  usually  does,  to  make  its 
turn  forward  until  it  has  passed  the  bony  outlet  and 

begun  to  distend 

^  the     perineum, 

*'      **,  it  turns  forward 

while     in     the 

pelvic       cavity, 

the   turn  being 

produced  by  the 

bones,     instead 

of  by  the  pelvic 

floor,  as  is  usual. 

But    when    the 

\c  deformity         is 

/     very   great   the 

rO    occiput    cannot 

turn    forwards, 

because  the 

pubic  rami   are 

so  close  together 

that  there  is  not 

room     for     the 

occiput  to  pass 

out        between 

them.      In  that 

case     it     turns 

back,  guided  by  the  bones,  and,  if  it  be  small  enough, 

the  head  emerges  in  an  oblique  diameter  through  the 

space  bounded  by  the  ischia  in  front  and  the  coccyx 

behind.     It  has  been  seen  thus  to  be  turned  back  by 

the  bones,  and  then,  when  the  head  had  passed  the 

bones,  the   soft  parts  turned    the   occiput   forwards, 

there  being   room   for  the  neck  between  the   pubis 

bones,  though  not  for  the  head.* 

Treatment. — In  any  patient  with  kyphosis  of  the 
spine  the  pelvic  outlet  should  be  carefully  measured. 
But  it  is  so  difficult  to  measure  accurately  the  outlet 
*  See  Champneys,  Obet.  Trans.,  vols.  xxv.  and  ixviij. 


Pig.  97.—  Diagram  of  Brim  of  Kyphotic  Pelvis. 

Continuous  line,  noimal  pelvis ;  dotted  line,  kyphotic 
pelvis ;  A,  symphysis ;  B  B,  eacro-iliac  sychond- 
roses  ;  0  0,  transverse  diameter;  d  d,  ilio- pectineal 
eminences ;  middle  of  sacrum  in  plane  of  brim. 


The   Kyphotic  Pelvis.  225 

that  it  is  not  possible,  unless  the  deformity  be  extreme, 
to  predict  difficulty  in  labour.  Even  if  the  measure- 
ments are  small,  they  may  be  slightly  increased  owing 
to  mobility  of  the  pelvic  joints.  But  if  the  distance 
between  the  tubera  ischiorum,  at  the  point  of  insertion 
of  the  sacro-sciatic  ligaments,  is  not  more  than  three 
inches,  labour  should  be  induced  at  the  end  of  the 
seventh  month.  If  there  be  doubt,  let  the  pregnancy 
take  its  course,  and  then,  from  information  gained  in 
the  first  labour,  advise  as  to  the  induction  of  labour 
or  not,  in  the  event  of  subsequent  pregnancy.  When 
labour  has  begun  there  is  no  advantage  in  turning.  If 
delivery  is  difficult,  use  forceps.  If  this  fail,  perforate. 
The  kyphotic  pelvis  is  very  rarely  so  contracted  as  to 
call  for  Caesarian  section,  but  cases  have  occurred  in 
which  this  was  necessary.  Such  extreme  deformity 
as  this  ought  to  be  recognised  early  in  labour,  and 
the  operation  done  before  the  patient  is  exhausted. 
In  a  case  in  which  the  disproportion  between  the 
head  and  pelvis  is  only  just  enough  to  prevent  the 
birth  of  a  living  child,  delivery  of  a  living  child  might 
be  made  possible  by  symphysiotomy.  But  the  in- 
crease in  the  transverse  diameter  gained  by  symphy- 
siotomy is  not  as  great  as  the  increase  in  the 
conjugate.  It  is  difficult,  when  the  passage  of  the 
head  is  obstructed  by  the  approximation  of  the  tubera 
ischiorum,  to  be  certain  that  the  disproportion  is  so 
slight  that  symphysiotomy  is  suitable;  and  if  the 
operator's  judgment  on  this  point  be  wrong,  and  the 
disproportion  be  greater  than  he  thinks,  then  in 
delivery  the  ossa  innominata  will  be  too  widely 
separated,  and  the  urethra  or  even  the  bladder  may 
be  injured.  Hence,  with  the  kyphotic  pelvis,  be  very 
cautious  before  undertaking  symphysiotomy,  and  if 
in  doubt,  perform  it  not. 

The  kypho-skoliotic  rickety  pelvis.*— This, 

as  its  name  implies,  is  the  pelvis  produced  by  the 
combination  of  angular  and  lateral  curvature  of  the 

*  See  Professor  Leopold's  monograph,   "Das  skoliotisch   und 
kyphoskoliotisch  rachitische  Becken,"  Leipzig,  1S79. 

p-36 


226 


Diffkult  Labour. 


spine  in  a  rickety  subject  (Fig.  98).     The  kyphotic  and 
the  rickety  pelves  arc  almost  exactly  opposite  to  one 


Fig.  98.— Kypho-skolio-rachitic  Pelvis.     (After  Leopold.) 

another  in  shape.  This  pelvis  is  a  sort  of  compromise 
between  them.  The  sacral  promontory  is  drawn  up, 
the  tip  tilted  forward,  and  the  sacrum  lengthened  and 
straightened  from  above  downwards,  as  in  the  kyphotic 
pelvis  ;  but  it  presents  the  rickety  convexity  from  side 
to  side  and  thickening  of  the  epiphysal  lines.  The 
ilio-pectineal  line  is  longer  and  straighter,  the  con- 
jugate diameter  at  the  brim  increased,  the  transverse 


Kypho-skolio-rachitic  Pelvis.  227 


Fig.  99.— Diagram  of  Brim  of  Kypho-skolio-rachitic  Pelvis. 

Continuous  line,  normal  pelvis;  (lotted  line,  deformed  pelvis;  bb,  sacro-Hiac 
synchondrosis ;  e,  centre  of  sacrum  in  plane  of  brim ;  o  C,  transverse  diameter  ; 
d  d  pectineal  eminences ;  A,  symphysis  pubis. 

slightly  diminished,  as  in  the  kyphotic  pelvis,  but  not 
so  much  (Figs.  99,  99a).  The  transverse  at  the  outlet 
is  diminished     The  general  shape  of  the  pelvis  is  there- 


Fig.  99a. — Diagram  of  Cavity  of  Kypho-skolio-rachitic  Pelvis. 

Continuous  line,  normal  pelvis;  dotted  line,  deformed  pelvis:  ab,  true  conju- 
gate ;  AC,  diagonal  conjugate  j  c  d,  antero-posterior  diameter  of  outlet. 


228  Difficult  Labour. 

fore  funnel-shaped.  In  addition  to  this,  the  pelvis  is 
unsymmetrical,  the  sacro-cotyloid  diameter  on  the  side 
of  the  lumbar  convexity  being  shortened,  and  the  sym- 
physis pubis  pulled  over  to  the  opposite  side. 

The  description  above  given  is  that  of  the  usual  form 
of  kypho-skoliotic  pelvis.  Exceptional  pelves  have  been 
described,  due  to  exceptional  forms  of  curvature. 

Diagnosis. — This  will  be  suggested  by  the  kind  of 


Pig.  100.— Osteomalacic  Pelvis. 

spinal  curvature  present,  and  must  be  made  by  careful 
measurement  of  all  the  pelvic  diameters. 

Treatment. — This  depends  upon  the  size  of  the  pelvis, 
and  whether  the  pelvis  approaches  more  to  the  kyphotic 
or  the  rickety  type.  According  to  this,  the  treatment 
is  that  either  of  the  kyphotic  or  the  rickety  pelvis. 

The  next  form  of  contracted  pelvis  I  describe 
resembles  the  rickety  pelvis  in  being  due  to  softening 
of  the  bones. 

The  osteomalacic  pelvis. — Osteomalacia  is  a 
disease  endemic  in  certain  parts  of  Europe,  but  very 
rare  in  England.* 

It  produces  extreme  softening  of  the  bones,  much 
greater  than  is  ever  found  in  rickets.     The  softening 

*  For  a  full  account  of  this  disease  see  Ritchie,  Edin.  Olst. 
Tram.,  Vol.  xxi.,  1895-6. 


The   Osteomalacic  Pelvis.  229 

is  so  great  that  the  bones  yield  to  the  pull  of  the 
muscles,  as  well  as  to  the  body  weight.  The  muscles 
pull  out  the  ischia,  pubic  rami,  and  ilia,  and  drive 
in  the  heads  of  the  femora,  crumpling  inwards  the 
acetabula.  When  the  acetabula  have  been  so  far  bent 
in  that  the  line  of  upward  pressure  of  the  heads  of  the 
femora  is  internal  to  the  sacro-iliac  synchondroses,  then 
the  reaction  of  the  femora  to  the  body  weight  acts 
inwards  and  upwards,  and  presses  the  acetabula 
towards  the  middle  line.  Hence  results  the  charac- 
teristic Y-shape  of  the  brim  of  the  osteomalacic  pelvis 
(Fig.  1 00).  The  tubera  ischiorum  are  pulled  out  by  the 
muscles  attached  to  them.  The  sacrum  yields  to  the 
body  weight,  as  in  the  rickety  pelvis,  but  more.  The 
promontory  is  pressed  down  and  forwards  so  far  that 
the  fifth  or  even  the  fourth  lumbar  vertebra  may  come 
to  lie  in  the  plane  of  the  brim.  As  the  central  part  of 
the  bone  is  pressed  down  by  the  body  weight,  while 
the  lateral  masses  are  held  up  by  the  ligaments  passing 
from  them  to  the  ilia,  the  sacrum  becomes  extremely 
convex  from  side  to  side.  From  this  curvature  it  is 
also  narrowed  transversely. 

The  sacro-iliac  ligaments  pull  the  posterior  superior 
iliac  spines  inwards.  The  sacro-sciatic  ligaments 
prevent  the  lower  end  of  the  sacrum  from  retreating 
backwards,  as  the  pushing  down  and  forwards  of  the 
promontory  would  otherwise  make  it  do :  hence  the 
lower  part  of  the  sacrum  is  sharply  curved  forwards, 
as  in  the  rickety  pelvis,  but  more  so,  so  that  the 
projection  of  its  point  contracts  the  pelvic  outlet. 
Sometimes  the  sacrum  is  not  only  deformed,  but  has 
slipped  forwards,  so  that  a  part  of  the  auricular  surface 
of  the  ilium  which  should  be  in  contact  with  the 
sacrum  is  uncovered  by  it ;  and  sometimes  the  ilium 
is  80  bent  that  the  sacrum  and  ilium  are  separated 
from  one  another  at  part  of  the  synchondrosis.  The 
ilia  are  so  crumpled  by  the  pull  downwards  of  the 
sacral  ligaments  behind,  and  the  push  upwards  of  the 
femora  in  front,  that  the  shape  of  the  bone  forms  a 
deep  furrow  between   the   sacrum   and   acetabulum. 


230  Difficult  Labour. 

The  two  pubic  bones  are  pressed  together  so  that  the 
symphysis  sticks  out  like  a  beak :  hence  this  pelvis 
is  sometimes  called  the  "  rostrate  "  pelvis. 

The  bones  are  so  soft  that  the  patients  cannot 
stand  or  walk,  but  sit  or  lie  in  various  attitudes.  The 
deformity  is  often  unsymmetrical,  from  the  patient's 
attitude  causing  the  pressure  on  the  two  sides  to  be 
unequal.  Further,  the  bones  may  be  at  some  places 
softer  than  at  others,  and  this  will  modify  the  manner 
in  which  they  yield  to  pressure.  Therefore,  all  osteo 
malacic  pelves  are  not  exactly  alike,  although  the 
general  type  above  described  holds  good. 

Diagnosis. — Osteomalacia  begins  during  preg- 
nancy or  lactation.  It  is  accompanied  by  severe  pain, 
especially  on  movement.  The  spine  becomes  curved, 
hence  the  length  of  the  trunk  is  diminished.  There 
are  cough,  shortness  of  breath,  suffocative  attacks, 
mnscular  cramps.  There  is  an  excessive  excretion 
of  phosphatic  salts  in  the  urine.*  After  the  removal 
of  the  ovaries  this  excess  of  phosphates  disappears, 
pain  ceases,  and  the  bones  harden.  It  has  been 
found  that  removal  of  the  ovaries  in  healthy  animals 
is  followed  by  lessening  of  the  amount  of  phosphates 
in  the  urine,  t  These  facts  point  to  a  dependence 
of  osteomalacia  upon  an  excess  of  the  internal 
secretion  of  the  ovary.  The  older  physicians  thought 
that  excessive  excretion  of  phosphates  depended  upon 
disorders  of  the  nervous  system,  of  which  excessive 
activity  of  the  genital  organs  was  one  of  the  causes. 
This  theory  was  much  used  by  quacks  for  their  own 
purposes :  but  it  would  seem  not  to  have  been  alto- 
gether without  foundation. 

The  diagnostic  signs  on  examination  are  two — (1) 
the  extreme  tenderness  of  the  bones;  (2)  their  softness, 
so  that  the  pelvis  can  be  forced  open  with  the  hand. 
The  shape  and  dimensions  of  the  pelvis  are  ascer- 
tained with  sufficient  exactness  by  digital  exploration. 

*  See  Neumann,  Arch,  fur  Gyn.,  Band  xlvii. 
t  See  Curatolo,  Obst.  Trans.,  vol.  xxxviii.,  1896. 


Osteomalacic  Pelvis.  231 

The  deformity  is  so  extreme  that  exact  measurement 
is  not  needed. 

Treatment. — The  projection  of  the  promontory  in 
osteomalacia  may  lead  to  incarcei'ation  of  the  pregnant 
uterus  and  retention  of  urine,  with  its  effects.  In  such 
a  case,  after  emptying  the  bladder,  tell  the  patient 
that  removal  of  the  ovaries  will  cure  her,  and  that 
she  should  have  this  done  without  delay ;  that  the 
operation  will  probably  not  interfere  with  her  preg- 
nancy, and  that  if  she  wishes  a  living  child  she  can 
be  delivered  at  or  near  full  term  by  Caesarian  section. 
She  has  a  right  to  decline  to  run  this  risk,  and  if  so. 
put  a  tent  in  the  cervix,  and  after  the  tent  has 
expanded  empty  the  uterus. 

At  term,  if  the  disease  is  active  and  the  bones  are 
soft,  it  may  be  possible  with  the  hand  to  force  apart 
the  bones,  and  thus  open  up  the  pelvis  enough  for 
delivery  to  take  place.  This  has  several  times  been 
done.     Try  first  to  do  this. 

If  the  pelvis  cannot  be  forced  open,  deliver  by 
Caesarian  section  followed  by  removal  of  the  body  of 
the  uterus  and  the  ovaries,  if  these  have  not  been 
already  removed,  or  by  Porro's  operation,  according 
to  your  skill  as  an  operator  and  the  circumstances  in 
which  you  operate.  Porro's  operation  is  a  proper 
mode  of  delivery  in  osteomalacia,  because  the  disease 
is  cured  by  removal  of  the  ovaries.  It  may  get  well 
— that  is,  the  pains  cease  and  the  bones  get  hard — 
spontaneously,  but  we  know  of  nothing  that  will  cure 
it  except  removal  of  the  ovaries. 

Osteomalacia  goes  on  so  fast  during  pregnancy  that 
by  the  time  term  is  reached  the  deformity  is  extreme. 
In  a  slight  case,  just  beginning  before  delivery,  which 
had  only  had  time  to  produce  slight  deformity,  the 
deformity  would  probably  not  be  noticed,  as  the  bones 
would  yield  before  the  hand,  especially  if  aid  were 
given  by  pulling.  Hence  we  only  have  to  consider 
treatment  in  extreme  degrees  of  deformity 

The  Naegele  pelvis. — The  obliquely-contracted 
pelvis  of  Naegele  (first  discovered  by  him  in  1832) 


232  Difficult  Labour. 

is  due  to  defective  development  of  the  lateral  mass 
of  the  sacrum,  and  bony  union  of  the  sacrum  with 
the  ilium  on  one  side.  In  every  respect  but  this  the 
bones  are  healthy  (Fig.  101). 

From  this  deformity  the  pressure  of  the  body 
weight  and  the  counter-pressure  of  the  femora  act 
unequally  on  the  two  sides.  The  pressure  of  the 
femora  is  upwards,  and,  being  outside  the  line  along 

n 


Fig.  101.— Obliquely-contracted  Pelvis  of  Naegele. 


which  the  body  weight  is  transmitted  from  the  sacrum 
to  the  feet,  tends  to  move  the  acetabula  outwards. 
On  the  diseased  side  the  femur  is  nearer  the  middle 
line  than  on  the  sound  side.  Therefore  on  this  side 
the  pressure  is  mainly  upwards,  very  little  outwards. 
On  the  sound  side  the  outward  pressure  is  exerted 
to  greater  advantage,  and  therefore  the  directly 
upward  pressure  is  less.  Hence  on  the  sound 
side  the  acetabulum  is  pushed  farther  outwards 
than  usual ;  the  wing  of  the  ilium  looks  more  for- 
wards and  less  inwards  than  usual ;  the  symphysis 
pubis  is  pulled  over  to  the  sound  side  (Fig.  102). 
On  the  diseased  side,  in  consequence  of  the  more 
directly    upward   pressure,    the    ilium   between   the 


The  Oblique  Pelvis  of  Naegele.       233 

acetabulum   and    synchondrosis    is   compressed    and 
therefore  thickened. 

The  Naegele  pelvis  is  very  rare.  We  know  nothing 
whatever  about  its  causes.  It  is  certain  that  it  is 
due  to  a  developmental  defect,  and  not  to  disease, 
because  all  specimens  are  exactly  alike  and  there  is 
no  sign  of  bone  disease.  There  is  no  histoiy  of  any 
injury  or  disease  or  lameness.  The  patient  is  un- 
aware of  any  disease  or  deformity.  The  defective 
development  of  the  sacrum  is  the  essential  condition 


\ 
\ 

\ 

\ 

\ 

XT  / 

Fig.  102.— Diagram  of  the  Brim  of  the  Oblique  Pelvis  of  Naegele. 

Continuous  line,  normal  pelvis;  dotted  line,  oblique  pelvis;  B  B,  sacrum;  cc 
acetabula ;  a,  symphysis  pubis. 


for  its  formation,  and  not  the  ankylosis,  for  in  some 
cases  there  is  no  ankylosis,  and  yet  the  oblique  de- 
formity is  present. 

Diagnosis. — Examine  the  patient  on  her  back. 
Trace  the  outline  of  the  iliac  crests,  and  notice  their 
asymmetry.  Note  the  displacement  of  the  pubic 
symphysis  towards  the  side  on  which  the  ilium  looks 
forwards.  Examine  the  back,  and  measure  the  dis- 
tance between  the  posterior  superior  iliac  spines  and 
the  sacral  spines.  The  distance  will  be  less  on  the 
diseased  side.  Take  with  callipers  the  distance  between 
the  posterior  superior  iliac  spine  of  one  side  and  the 
anterior  superior  iliac  spine  on  the  other.  That 
measurement  will  be  the  greater  which  starts  from 


234  Difficult  Labour. 

the  diseased  side  behind.  Finally,  examine  by  the 
vagina,  and  feel  the  outline  of  the  pelvic  wall  as  far 
as  you  can.  You  will  be  able  to  feel  nearly  the 
anterior  half,  and  to  perceive  the  different  shape  on 
the  two  sides. 

The  important  point  obstetrically  is  the  diminution 
of  the  oblique  diameter  taken  from  the  sacroiliac 
synchondrosis  on  the  sound  side  to  a  point  above  the 
middle  of  the  obturator  foramen  on  the  side  of  the 
ankylosis.  This  can  only  be  measured  during  life  by 
inserting  the  whole  hand.  If  the  labour  is  to  end 
naturally  the  head  must  be  small,  and  it  must  enter 
the  pelvis  with  the  occiput  towards  the  obturator 
foramen  on  the  sound  side.  In  the  labours  which 
have  been  reported,  only  about  a  quarter  of  the 
children  survived. 

The  treatment  of  pregnancy  with  a  Naegele  pelvis 
is  to  give  the  patient  the  choice  between  induction  of 
premature  labour  and  Caesarian  section.  At  term,  if 
the  head  is  small  enough  to  come  down  into  the 
pelvis,  leave  it  to  nature.  If  the  head  is  so  large 
that  it  cannot  enter  the  brim,  the  choice  is  between 
Caesarian  section  and  cephalotripsy.  The  considera- 
tions to  be  put  before  the  patient  to  help  her  to 
choose  will  be  stated  in  a  later  chapter.  If  the  head 
has  entered  the  brim  but  makes  not  progress,  try  the 
forceps ;  but  if  the  instrument  slips  or  brings  not 
quickly  down  the  head,  do  not  prolong  the  trial,  but 
perforate.  There  is  no  advantage  in  turning,  and 
very  little  in  symphysiotomy.  The  remarks  made 
upon  symphysiotomy  in  labour  with  the  kyphotic 
pelvis;  apply  also  to  labour  with  this  pelvis,  but  with 
greater  force. 

The     transversely  -  contracted     pelvis     of 

Robert. — This  is  one  of  the  rarest  contracted  pelves. 
Eight  specimens  only  have  been  described.  In  it 
there  is  deficient  development  of  the  lateral  mass  of 
tho  sacrum  on  both  sides,  and  ankylosis  of  the  sacrum 
to  the  ilia  (Fig.  103).  The  narrowness  of  the  sacrum 
contracts  the  pelvis  transversely ;  and  in  addition,  from 


Transversely-Contracted  Pelvis.       235 

the  pressure  of  the  femora  being  applied  so  near  the 
middle  line,  the  ossa  innominata  are  not  pressed  apart 
so  much  as  usual.  The  sacrum  is  pushed  slightly 
forwards  between  the  ilia,  and  the  ilia  are  less  curved. 
From  the  great  vertical  pressure  upon  it,  the  sacrum 
is  convex  from  -side  to  side,  and  its  upper  part  is  con- 
vex from  above  downwards. 

Some  pelves  have  been  described  under  this  title 
in  which  the  lateral  masses  of  the  sacrum  were 
unequal  in  their  defect  of  development,  so  that  the 


Fig.  103.— Transversely-contracted  Pelvis  of  Robert. 

pelves  were  asymmetrical  Such  pelves  form  a  tran- 
sition between  the  oblique  pelvis  of  Naegele  and  the 
transversely-contracted  pelvis  of  Robert. 

Two  pelves  have  been  described,  in  each  of  which 
not  simply  the  lateral  masses,  but  the  greater  part  of 
the  body  of  the  sacrum,  was  wanting.  I  need  not 
give  further  details  of  these  curiosities. 

The  diagnosis  is  made  by  the  transverse  measure- 
ments :  those  between  the  iliac  crests,  anterior 
and  posterior,  iliac  spines,  and  the  trochanters — all 
these  are  diminished.  By  internal  examination,  the 
closeness  of  the  ischial  tuberosities,  the  small  angle 


236  Difficult  Labour. 

which  the  pubic  bones  make  with  one  another,  and  the 
high  position  of  the  promontory  will  be  recognised 
without  difficulty. 

The  treatment  consists,  if  the  patient  is  seen  within 
the  first  four  months  of  pregnancy,  in  giving  her  the 
choice  between  going  to  full  term,  to  be  then  delivered 
by  Caesarian  section,  and  the  induction  of  abortion. 
If  the  latter  is  clone,  it  is  not  easy  to  empty  the  uterus 
on  account  of  the  difficulty  of  getting  at  it,  owing  to 


Kg.  104.— Lumbar  Vertebra  :  showing  the  defect  in  ossification  upon 
which  spondyl-olisthesis  depends.  {From  a  specimen  in  the  London 
Hospital  Museum.) 

the  depth  and  narrowness  of  the  pelvis.  After  this 
date  the  patient  must  go  to  term,  and  then  be  de- 
livered by  Caesarian  section. 

Spondyl-olisthesis. — This  means  a  slipping  of  a 
vertebra  (from  owovSvXog,  a  vertebra,  and  oXiVflf/ortc, 
slipping).  It  is  the  pelvic  deformity  produced  by  the 
slipping  forward  of  the  body  of  the  last  lumbar 
vertebra  on  the  sacrum. 

It  is  produced  by  the  coincidence  of  two  con- 
ditions:  (1)  a  malformation;  (2)  strain.  1.  The 
malformation  (Fig.  104).  It  is  not  uncommon  for  the 
ossification  of  the  last  lumbar  vertebra  to  be  imperfect 
from  non-union  of  parts  ossified  from  different  centres, 
so  that  at  the  part  of  the  bony  ring  between  the  upper 
and  lower  articular  processes  there  is  a  gap  filled  with 
cartilage    or    with    fibrous    tissue.     While   spondyi- 


Spond  yl-olis  thesis. 


237 


olisthesis  is  rare,  this  bony  defect  (called  spondylysis 
articularis)  is  common.  It  is  not  by  itself  sufficient 
to  produce  the  deformity.  2.  Strain.  If  a  patient 
with  this  malformation  has  to  do  very  heavy  labour, 
or  if  by  violence  the  spinal  column  is  suddenly  driven 
down,  the  last  lumbar  vertebra  may  give  way  at  this 
weak  spot,  and  the  body  of  the  vertebra,  with  the 
upper  articular  processes,  slip  forwards,  while  the  rest 


Pig.  105.— Spondylolisthesis:    (After  Kilian.) 

of  the  bone  remains  in  its  place.  This  will  take  place 
gradually  if  from  over-strain,  suddenly  if  from  violence. 
In  one  case  the  pedicles  of  the  three  lower  lumbar  ver- 
tebra were  found  separated,*  but  we  have  no  expla- 
nation how  this  came  about.  It  is  believed  by  some 
that  spondylolisthesis  may  arise  without  any  defect 
in  ossification,  by  (1)  fracture  of  the  articular  pro- 
cesses of  the  sacrum,  thus  letting  the  last  lumbar  ver- 
tebra, with  the  articular  processes  of  the  sacrum,  slide 
forward  ;  or  (2)  fracture  of  the  interarticular  portion 
of  a  properly  ossified  last  lumbar  vertebra.     Both  these 

*  Targett,  Obst.  Trans.,  Vol.  xxxiii.,  189L 


238  Difficult  Labour. 

occurrences  are  hypothetical.  The  mode  of  ox*igin 
first  described  is  the  only  one  that  has  been  demon- 
strated and  explained. 

Secondary  changes. — When  this  dislocation  has 
occurred,  the  altered  mechanical  conditions  under 
which  the  bones  concerned  are  placed  produces 
changes  in  them  (Fig.  105).  From  the  dislocation 
(a)  the  canal  of  the  last  lumbar  vertebra  is  enlarged 
from  before  backwards,  (b)  The  body  of  the  vertebra, 
in  its  new  position,  is  not  supported  in  front,  so  that 
it  sinks  down,  and  its  anterior  part  forms  an  angle, 
opening  downwards,  with  its  posterior,  (c)  Between 
the  sacrum  and  the  vertebra  above,  it  is  compressed 
behind,  so  that  it  becomes  the  shape  of  a  blunt  wedge, 
the  base  of  the  wedge  being  in  front.  (d)  The 
slipping  forward  of  the  last  lumbar  vertebra  throws 
unusual  strain  on  the  intervertebral  substance 
between  it  and  the  first  sacral  vertebra,  (e)  The 
result  of  this  strain  is  the  growth  of  bone  in  the 
intervertebral  substance,  and  in  the  angle  between 
the  displaced  lumbar  vertebra  and  the  first  sacral 
vertebra.  This  ossification  tends  to  prevent  further 
dislocation,  and  therefore  is  a  conservative  change. 

The  deformity  has  been  divided  into  four  stages, 
according  to  the  degree  of  displacement  of  the  last 
lumbar  vertebra  :  (1)  when  it  projects,  (2)  hangs  over 
towards  the  pelvic  brim,  (3)  has  sunk  into  the  brim, 
(4)  has  sunk  into  the  pelvic  cavity. 

The  sacrum  is  altered.  Instead  of  the  body 
weight  (transmitted  through  the  spine)  pressing  down 
on  the  upper  surface  of  the  sacrum,  it  presses  down 
and  back  on  the  front  edge  of  this  surface.  Hence 
the  upper  part  of  the  sacrum  is  displaced  backwarda 
This  backward  pressure  on  the  sacrum  tends  to  flatten 
and  narrow  the  sacral  canal. 

There  is  extreme  lordosis  of  the  lumbar  spine,  so 
that  the  front  edges  of  the  bodies  of  the  vertebrae  are 
farther  apart  than  they  should  be,  while  the  hinder 
parts — the  articular  processes  and  neural  arches — are 
pressed  together,  and  this  pressure  may  lead  to  bony 


Spondylolisthesis.  239 

outgrowths,  ossification  of  the  ligaments,  and  finally 
synostosis. 

The  sacrum  being  pressed  backwards,  separates 
the  ilia  and  makes  the  posterior  superior  iliac  spines 
farther  apart  from  one  another. 

The  inclination  of  the  pelvis  to  the  horizon  is 
diminished,  and  the  effect  of  this  is  to  throw  increased 
strain  on  the  iliofemoral  ligaments.  The  pull  of  this 
ligament  rotates  each  os  innominatum  about  an 
anteroposterior  axis,  so  that  the  upper  part  of  the 
bone  is  turned  outwards,  the  lower  part  inwards  (as  in 
the  kyphotic  pelvis).  Hence  the  transverse  diameter 
at  the  brim  is  widened,  at  the  outlet  narrowed.  The 
spondylolisthetic  pelvis  thus  has  the  general  characters 
of  the  kyphotic  pelvis,  plus  great  contraction  in  the 
conjugate  of  the  brim.  The  extent  to  which  these 
changes  go  depends  upon  the  degree  of  the  spondyl- 
olisthesis. 

The  defect  in  ossification  upon  which  spondyl- 
olisthesis depends  may  be  present  on  only  one  side. 
In  that  case  the  last  lumbar  vertebra  will  slip 
forwards  more  easily  on  the  side  of  the  spondylysis, 
and  an  unsymmetrical  deformity  will  result.  But  the 
disease  is  so  rare  that  I  need  not  describe  the  various 
modifications  in  particular  specimens  due  to  the 
greater  or  less  advance  of  the  morbid  change,  and  to 
its  more  or  less  asymmetry. 

Diagnosis. — The  investigation  of  a  case  of  sup- 
posed spondylolisthesis  is  conducted  along  three  lines. 

First,  the  history.  This  will  be  of  some  violence 
or  strain,  leading  to  a  long  illness  severe  enough  to 
keep  the  patient  in  bed,  and  attended  with  pain  in 
the  lower  part  of  the  back.  The  usual  date  of  this 
illness  is  about  from  the  fifteenth  to  the  eighteenth 
year  of  life. 

Second,  the  shape  oj  the  body.  The  patient  is  short, 
and  this  diminution  of  stature  is  from  shortening 
of  the  lumbar  spine.  There  is  great  lordosis.  The 
ribs  are  sunk  (in  a  bad  case)  into  the  false  pelvis. 
This  makes  conspicuous  the  great  breadth  between 


240 


Difficult  Labour. 


the  wings  of  the  ilia.  The  back  of  the  sacrum  is 
plainly  felt,  and  the  posterior  superior  iliac  spines  are 
farther  apart  than  usual.  From  the  less  inclination 
of  the  pelvis  the  genitals  look  more  forwards  than 
usual,  less  downwards.  The  patient  walks  with  short 
steps,  and  the  feet  are  slightly  inverted,  so  that  the 
mark  made  by  the  foot  is  deficient  in  breadth. 

Third,  examination  of  the  pelvis.  The  displaced 
lumbar  vertebra  is  felt  narrowing  the  brim.  It  is 
distinguished   from  the  projecting  promontory  of  a 


Fig    106.— Spondylizema. 


rickety  pelvis  by  the  facts  that  externally  no  dis- 
placement forwards  of  the  sacrum  is  perceived,  and 
that  on  the  side  of  the  projecting  vertebra  nothing 
like  the  lateral  masses  of  the  sacrum  is  felt.  You 
must  not  expect  to  feel  a  distinct  angle  between  the 
displaced  lumbar  vertebra  and  the  sacrum,  because 
this  angle  is  filled  up  by  new  bone.  The  nearness  of 
the  ischia  to  one  another,  and  the  displacement  for- 
wards of  the  tip  of  the  sacrum  are  like  what  is  felt  in 
the  kyphotic  pelvis. 


Deformity  from  Fracture.  241 

In  caries  of  the  last  lumbar  vertebra  and  top  of 
the  sacrum  the  defoi-mity  produced  is  called  spondyl- 
izema  (Fig,  106).  In  this  case  the  angle  of  the  kyphosis 
may  be  so  acute  that  the  lower  lumbar  vertebrae  are 
inclined  over  the  pelvic  brim  like  a  roof :  hence  this 
pelvis,  and  the  spondylolisthetic  have  been  described 
under  the  common  name  of  the  pelvis  obteeta. 

Treatment. — The  treatment  of  labour  with  spondyl- 
olisthesis depends  upon  the  degree  of  the  deformity. 
This  is  estimated  by  the  length  of  the  obstetrical 
conjugate.  The  more  this  is  shortened  the  more 
marked  will  be  the  other  changes  in  the  pelvis  also. 
In  the  different  degrees  of  deformity  the  induction  of 
labour,  forceps,  turning,  craniotomy,  or  Caesai-ian 
section  should  be  chosen  according  to  the  rules  given 
for  the  treatment  of  labour  with  the  flat  pelvis. 

Deformity  from  fracture. — Pelvic  deformity 

may  be  produced  by  fracture  of  the  pelvic  bones.  I 
have  seen  a  case  in  which  the  pelvic  measurements, 
taken  during  life,  were  such  as  would  have  indicated 
the  transversely-contracted  pelvis  of  Robert,  were  it 
not  that  the  history  was  that  in  childhood  the  wheel 
of  a  cart  had  passed  over  the  patient's  pelvis. 
Asymmetrical  deformity  may  be  produced  by  fracture 
of  one  pelvic  bone  only.  But  fracture  of  the  pelvic 
bones  is  so  often  accompanied  by  fatal  injury  to  the 
viscera,  that  cases  are  rare  in  which  difficult  labour  is 
due  to  deformities  caused  by  fracture.  The  possible 
seat  of  the  injury,  the  number  of  the  fractures,  the 
dislocation  of  the  fragments,  etc.,  are  too  various  to 
admit  of  description. 

The  treatment  must  depend  upon  the  data  gained 
by  careful  measurement  of  the  pelvis. 

The  COXalgic  pelvis. — Disease  of  the  hip-joint 
occurring  in  childhood,  and  leading  as  it  does  to 
altered  nutrition  of  one  side  of  the  pelvis,  to  non-use 
of  one  limb,  and  often  to  dislocation  of  the  head  of  the 
femur,  is  accompanied  with  deformity  of  the  pelvis. 
The  deformity  varies  so  much  with  the  extent  of  the 
disease,  the  age  of  the  patient,  and  the  presence  or 
Q— 36 


2.}2 


Difficult  Labour. 


absence  of  dislocation,  that  general  statements  as  to 
the  nature  of  the  deformity  cannot  be  made.  All  that 
can  be  said  is  that  long-standing  hip  disease  in  children 
does  produce  deformity. 

There  are  some  other  pelvic  deformities  which  do 
not  make  labour  difficult,  but  which  are  important  on 
account  of  the  light  they  throw  on  the  forces  which 
mould  the  pelvis  during  growth. 

The  fcetal  or  lying-down  pelvis. — This  is  a  very 
rare  form  of  pelvis  occurring  in  subjects  who,  although 


Fig.  107.  —Split  Pelvis. 

they  have  reached  adult  age,  have  never  walked,  and 
whose  genital  organs  have  never  developed.  In  this 
case  the*  changes  produced  in  the  shape  of  the  pelvis 
during  growth  by  the  pressure  of  the  body  weight  and 
the  upward  reacting  pressure  of  the  femora,  do  not 
occur,  and  the  pelvis  remains  of  the  same  shape  as 
that  of  the  foetus. 

As  the  genital  organs  in  these  cases  are  not  devel- 
oped, there  is  no  obstetric  history  to  the  foetal  pelvis. 
Its  value  is  thatit  shows  theinfluenceof  theupward  pres- 
sure of  the  femora  in  widening  the  pelvis ;  that  when 
this  pressure  has  not  acted,  the  pelvis  is  not  widened. 


The  Split  Pelvis. 


243 


The  Split  pelvis  (Fig.  107). — In  this  deformity 
the  symphysis  pubis  is  absent.  The  result  is  that  the 
tendency  of  the  pressure  of  the  femora  to  press  out- 
wards the  acetabula  is  not  so  powerfully  opposed  as  in 
a  normal  condition.  The  bones  are  united  in  front  by 
some  fibrous  tissue,  but  this  is  a  weak  tie  compared  to 
the  normal  joint.  There  is  at  birth  a  gap  between  the 
pubic  bones,  and  during  growth  this  gap  is  increased. 
The  upward  pressure  of  the  femora  rotates  the  bones 


Fig.  108.  —Pelvis  of  Congenital  Dislocation  of  the  Hips. 

about  the  sacrum,  so  that  the  posterior  iliac  spines 
approach  one  another.  This  shortens  the  distance 
spanned  by  the  ligaments  suspending  the  sacrum  from 
the  ossa  innominata,  and  therefore  the  sacrum  is 
allowed  to  slip  forwards  and  downwards.  The 
approach  to  one  another  of  the  posterior  iliac  spines 
and  the  sinking  forwards  of  the  sacrum  in  extreme 
cases  reaches  such  a  degree  that  it  looks  as  if  the 
bones  enclosed  a  canal  behind  instead  of  in  front,  and 
this  has  led  Ahlfeld  to  give  it  the  name  of  the 
"  inverted  pelvis."     The  general  outline  of  the  pelvis 


244  Difficult  Labour. 

is  that  of  an  extreme  form  of  rickety  pelvis,  but  the 
gap  in  front  prevents  it  from  causing  any  great 
difficulty  in  labour.  Only  seven  cases  of  labour  with 
this  pelvic  deformity  have  been  recorded.* 

This  pelvis  is  interesting  as  showing  the  direction 
in  which  the,  pressure  of  the  femora  really  acts.  If 
the  femora  pressed  inwards,  they  should  press  the  two 
pubic  bones  together  ;  but  they  do  not. 

It  is  almost  always  associated  with  extroversion  of 
the  bladder,  and  therefore  pregnancy  with  it  is  rare.t 

The  pelvis  of  so-called  congenital  disloca- 
tion of  the  hips. — This  is  a  very  interesting  pelvis, 
although  it  gives  rise  to  no  difficulty  in  labour, 
because  it  shows  the  effect  of  altered  pull  of  muscles 
in  changing  the  shape  of  the  pelvis. 

The  so-called  dislocation  is  due  to  a  defect  in  the 
acetabula,  so  that  the  heads  of  the  femora  slip  up  on 
to  the  dorsa  iliorum.  The  upper  end  of  the  femur  is 
therefore  higher  up  than  it  ought  to  be.  The  result 
is  that  the  origins  and  insertions  of  the  glutei  muscles 
are  brought  nearer  together.  Hence  the  glutei  do 
not  pull  out  the  alee  of  the  ilia  as  much  as  usual,  and 
therefore  they  are  steeper,  more  nearly  vertical  than 
normal  (Fig.  108).  The  origins  and  insertions  of  the 
muscles  passing  from  the  tubera  ischiorum  to  the  femur 
are,  on  the  contrary,  brought  farther  away  from  one 
another ;  and  hence  the  tubera  ischiorum  are  pulled 
out  more  strongly  than  usual,  and  the  outlet  of  the 
pelvis  is  consequently  widened.  These  are  the  main 
changes.  The  pelvic  bones  are  very  slender.  This  is 
probably  because  the  defect  in  growth  which  makes 
the  acetabula  imperfect  affects  also  the  thickness  of 
the  bones.  The  pelvis  is  also  much  inclined  to  the 
horizon,  the  sacrum  being  more  nearly  horizontal 
than  usual.  This  is  from  the  pull  of  the  ilio-femoral 
ligaments  and  the  iliacus  muscle,  the  attachments  of 
which  to  the  femur   are   carried   by  the   dislocation 

*  For  an  account  of  them,  see  Tlieodor  Klein,  Arch,  fiir  Gyn.t 
Band  xliii. 

t  bee  Klein,  Arch,  fiir  Gyn.,  Bd.  xliii. 


Congenital   Dislocation  of  Femora.    245 

farther  away  from  their  pelvic  origins.  The  femora, 
when  dislocated,  lie  in  a  socket  formed  by  fibrous 
tissue  attached  to  the  dorsum  of  the  ilium,  and 
support  the  pelvis  by  the  pull  of  this  fibrous  tissue. 
This  pull  is  applied  a  little  farther  out  than  the 
highest  part  of  the  acetabulum.  Hence  the  outward 
pressure  of  the  femora  is  applied  to  a  little  greater 
advantage  than  in  the  normal  pelvis,  and  the  pelvis 
is  consequently  slightly  widened. 

When  the  dislocation  is  on  one  side  only,  the 
pelvis  is  widened  slightly  on  that  side,  and  the 
symphysis  is  pulled  a  little  over  to  the  side  of  the 
dislocation.  * 

Mixed  forms. — Lastly,  in  the  shape  of  the  pelvis 
as  well  as  in  the  other  bodily  structures,  and  in  the 
features  of  disease,  we  get  anomalous  cases  that  are 
exceptions  to  the  rules  which  hold  good  of  pelves 
generally.  A  negro,  with  his  black  skin,  woolly 
hair,  flat  nose,  and  prominent  jaw,  cannot  possibly  be 
taken  for  a  white  man,  yet  in  countries  where  the 
two  races  are  mixed  we  may  find  subjects  who  inherit 
negro  blood  and  yet  have  paler  skins,  straighter  hair, 
more  prominent  noses,  and  less  prominent  jaws  than 
some  white  men.  Just  so,  although  a  flat  pelvis  differs 
in  the  ways  that  have  been  described  from  a  small 
round  pelvis,  yet  we  may  have  exceptional  pelves 
presenting  some  features  of  one  form,  some  of  another. 
Thus  there  is  in  London  a  pelvis  the  measurements  of 
which  show  it  to  be  a  small  l'Oimd  pelvis,  but  its  sacral 
promontory  is  quite  low  down.  In  the  museum  of 
the  London  Hospital  there  is  a  pelvis  quite  normal 
as  to  all  its  measurements,  but  which  has  a  double 
promontory. 

*  In  some  text-books  other  changes  are  described  as  being  the 
result  of  one-sided  dislocation.  These  descriptions  are  got  by 
putting  together  all  sorts  of  dislocations  in  all  sorts  of  pelves.  A 
dislocation  in  a  rickety  pelvis,  or  one  the  result  of  caries  of  the 
acetabulum,  is  not  the  same  thing  as  a  congenital  dislocation  in 
an  otherwise  normal  pelvis.  In  the  latter  the  changes  are  as 
described  above. 


246 


CHAPTER    XVIII. 

SLOW   DILATATION    OP    THE   SOFT    PARTS. 

Labour  may  be  slow  when  there  is  no  bony  obstruction, 
malposition,  or  excessive  size  of  the  child ;  the  soft 
parts  may  be  long  in  becoming  canalised.  The  part 
that  has  to  be  most  dilated  is  the  cervix,  and  therefore 
delay  from  slow  dilatation  is  usually  in  the  first 
stage  of  labour. 

**  Rigidity  "  Of  the  cervix. — Slow  dilatation  ot 
the  cervix  uteri  in  labour  is  often  said  to  be  due  to 
rigidity  of  the  os  uteri.  Two  kinds  of  rigidity  are 
described,  or  implied,  in  most  text-books.  One  is 
rigidity  from  disease  recognisable  independently  of 
labour,  such  as  cancer,  fibroids,  scar  tissue,  etc.  Such 
cases  are  rare.  The  other  is  rigidity  of  a  cervix  which 
is  healthy,  but  presents  resistance  to  dilatation  which  is 
unusual,  and  supposed  to  be  abnormal.  These  cases  are 
very  rare,  if  they  exist  at  all,  but  in  the  experience 
of  unskilful  accoucheurs  are  very  common.  When  a 
healthy  cervix  does  not  dilate  properly  it  is  because 
the  natural  dilating  force  is  absent.  A  healthy  cervix 
will  always  dilate  when  the  bag  of  membranes  is 
driven  into  it :  and  the  rate  of  its  dilatation  depends 
mainly  upon  the  force  and  frequency  with  which  this 
natural  dilator  is  pressed  into  it. 

There  are  some  conditions  which  make  the  cervix 
slow  in  dilating.  What,  then,  are  the  causes  of  slow 
dilatation  of  the  cervix  ? 

1.  Premature  delivery. — During  the  last  few 

days  of  pregnancy  the  circular  fibres  round  the  internal 
os  are  inhibited;  and  the  longitudinal  fibres,  during  the 
painless  uterine  contractions  of  pregnancy,  pull  open 
the  internal  os,  so  that  the  cavity  of  the  cervix  becomes 
a  part  of  the  uterine  cavity.  This  is  the  prepara- 
tory stage  of  labour.     Sometimes  the  internal  os  is 


Slow  Dilatation  of   Cervix.  247 

expanded,  and  the  membranes  rest  on  the  os  externum, 
as  early  as  the  seventh  month  of  pregnancy  :  but  this 
is  not  the  rule.  It  is  generally  supposed  that  this 
preparatory  stage  takes  place  during  the  last  fortnight 
of  pregnancy,  but  we  have  no  exact  knowledge  either 
as  to  the  frequency  of  variations  from  this  date  or  the 
conditions  on  which  such  variations  depend.  Exact 
knowledge  could  only  be  got  by  frequent  vaginal 
examination  throughout  pregnancy,  and  this  is  im- 
practicable. Now,  premature  labour  may  come  on  or 
be  induced  before  this  preparatory  stage  is  completed, 
or  even  begun.  If  this  be  so,  the  dilatation  of  the 
cervix  will  be  slow.  The  bag  of  membranes,  instead 
of  having  to  stretch  open  the  external  os  only,  has  to 
dilate  first  the  internal  os,  then  the  external.  There- 
fore a  slow  first  stage  is  natural  in  premature  labour. 

2.  Premature  rupture  of  the  membranes.— 
This  is  the  great  cause  of  slow  dilatation  of  the  os 
uteri  in  labour  at  term.  No  part  of  the  child  can 
come  down  into  the  os  while  it  is  small,  as  the  bag 
of  membranes  does.  This  is  a  mechanical  disadvantage, 
from  the  dilating  agent  being  an  imperfect  one.  The 
larger  the  os  is  when  the  membranes  rupture,  the  less 
the  disadvantage.  There  is  also  a  physiological 
disadvantage.  The  bag  of  membranes  pressing  into 
the  os  stimulates  by  reflex  action  the  body  of  the 
uterus.  When  the  bag  bursts  too  soon  and  the 
presenting  part  does  not  press  into  the  os,  this 
stimulant  is  wanting,  and  the  pains  are  consequently 
few  and  feeble. 

Suppose  now  that  this  misfortune  has  happened, 
how  should  the  case  be  treated  1 

Treatment. — If  the  child  be  presenting  with  the 
head  or  breech,  watch  the  effect  of  some  pains.  If 
the  presenting  part  comes  well  down  into  the  pelvis 
during  a  pain,  so  that  it  puts  the  cervix  on  the  stretch, 
and  can  be  pushed  up  between  the  pains  (this 
proving  that  there  is  not  impaction),  although  the 
dilatation  will  be  slow  (not  because  the  cervix  is  rigid, 
but  because  the  dilator  is  a  bad  one),  yet  it  will  b« 


248  Difficult  Labour. 

better  to  leave  the  process  to  nature.  Direct  your 
treatment  to  maintaining  the  patient's  nerve  force  by 
food  and  sleep.  If  the  pains  are  strong  and  frequent, 
see  that  the  patient  takes  plenty  of  food.  If  they  are 
weak  and  infrequent,  support  her  strength  by  food  in 
the  daytime,  and  at  night  (or  in  the  daytime  if  she  be 
sleepy),  give  her  chloral,  or  opium,  or  both,  so  that 
she  may  sleep,  and  her  nerve  force  be  recuperated. 
As  she  is  probably  anxious  and  in  pain,  she  will 
need  a  larger  dose  than  usual.  Tr.  opii  ^ss  may 
be  given,  or  gr.  xl  of  chloral :  or  tr.  opii  Tt\  xxv  with 
chloral  5ss.  Chloral  has  a  remarkable  effect  in  favour- 
ing dilatation  of  the  cervix;  but  whether  it  should  be 
called  a  specific  effect,  or  whether  its  action  on  the 
cervix  is  only  through  its  influence  in  calming  the 
nervous  system,  and  thus  restoring  nerve  force,  is  not 
quite  certain.  There  is  no  doubt  of  its  value.  A  warm 
bath  will  be  refreshing  and  perhaps  favour  dilatation. 

3.  The  presenting  part  cannot  enter  the 

brim. — Premature  rupture  of  the  membranes  often 
happens  because  the  presenting  part  does  not  fill  the 
os  uteri,  and  shut  off  the  "  fore  waters  "  from  the 
general  intra-uterine  pressure.  In  such  a  case  after 
rupture  of  the  membranes  the  presenting  part  does 
not  come  into  the  os  uteri  to  dilate  it.  This  may 
happen  either  from  transverse  presentation,  or  from 
contraction  of  the  pelvic  brim.  Premature  rupture  of 
membranes,  therefore,  if  rightly  understood,  may  be  a 
useful  warning  of  trouble  ahead.  If  the  case  be  let 
alone,  the  uterine  muscle  will  in  time  pull  open  the 
cervix.  But  it  will  take  a  long  time  to  do  it,  and  there 
will  be  danger,  if  the  head  is  above  the  brim,  of  the 
cervix  getting  nipped  between  the  head  and  the  pelvic 
brim,  and  so  being  prevented  from  rising. 

In  cases  of  this  kind,  as  soon  as  it  is  clear  that  the 
presenting  part  is  not  descending  into  the  cervix  to 
stretch  it  open,  the  best  practice  is  to  supply  the  place 
of  the  natural  dilator  by  an  artificial  one. 

Your  choice  of  a  dilator  must  depend  upon  cir- 
cumstances. Although  the  cervix  is  not  dilated,  it 
may  be  dilatable.     The  larger  the  os,  the  thinner  and 


Slow  Dilatation  of   Cervix.  249 

softer  its  margin,  the  more  likely  it  is  that  full  dilata- 
tion will  be  quickly  brought  about  by  a  dilating  force. 
This  condition — viz.  when  the  cervix,  though  not  fully 
dilated,  is  dilatable — is  the  only  one  in  which  delivery 
before  full  dilatation  of  the  cervix  is  good  treatment. 
If,  then,  the  os  uteri  is  big  enough  to  admit  four 
fingers,  and  its  thinness  and  softness,  together  with 
the  fact  that  the  presenting  part  does  not  put  it  on 
the  stretch  during  a  pain,  lead  you  to  infer  that  the 
absence  of  a  dilator  is  the  only  thing  at  fault,  examine 
carefully  the  size  of  the  pelvis,  the  size  and  position 
of  the  child.  If  the  vertex  is  presenting  in  a  favour- 
able position  and  the  equator  of  the  head  not  high 
above  the  brim,  put  on  forceps.  If  the  child  is 
transverse,  or  presenting  with  the  breech,  or  the  head 
in  an  unfavourable  position,  such  as  a  face  or  brow 
presentation,  bring  down  a  foot.  If  the  equator  of 
the  head  is  high  above  the  brim,  and  the  pelvic  brim 
is  so  contracted  that  you  judge  that  a  living  child  can- 
not be  born,  deliver  by  Caesarian  section,  symphysio- 
tomy, or  perforation.  The  reasons  which  should  guide 
choice  I  have  set  forth  elsewhere. 

If  the  os  will  admit  two  fingers,  but  not  moi'e, 
dilate  it  with  Champetier's  bag,  and  then  deliver  by 
the  means  the  conditions  present  indicate.  The  slow 
dilatation  is  here  merely  one  of  the  features  of  labour 
with  contracted  pelvis. 

4.  Primary  uterine  inertia. — Slow  expansion 

of  a  healthy  cervix,  the  membranes  being  entire,  is 
simply  due  to  weakness  of  the  pains.  It  requires  no 
treatment  but  patience,  and  5ss  of  chloral  not  oftener 
than  once  in  four  hours.  No  harm  (except  fatigue) 
can  result  from  prolongation  of  the  first  stage  of 
labour  with  the  membranes  intact. 

Sometimes  the  pains  in  the  first  stage  of  labour  are 
very  frequent  and  very  painful,  but  of  short  duration 
and  producing  little  effect.  I  think  it  probable  that 
pains  of  this  kind  may  be  the  beginning  of  the  "  pre- 
mature uterine  retraction "  described  in  chapter  xi. 
But,  as  I    have    found    treatment   effective,  I    have 


250  Difficult  Labour. 

not  seen  the  one  condition  pass  into  the  other,  and  my 
opinion  is  nothing  but  a  conjecture.  I  have  seen  this 
state  of  things  altered  in  a  wonderful  way  by  antipyrin. 
Ten  grains  given  every  two  hours  will  lessen  the 
suffering  and  convert  short,  frequent  weak  pains  into 
prolonged  effective  pains  at  longer  intervals.  This 
drug  has  no  influence  on  normal  labour. 

5.  Influence  Of  age. — The  soft  parts  stretch 
better  in  young  subjects  than  in  old.  Hence  in 
women  who  begin  to  have  children  late  in  life  the 
cervix  takes  longer  to  dilate,  and  the  first  stage  of 
labour  is  longer.  The  soft  parts  at  the  floor  of  the 
pelvis  do  not  stretch  so  easily,  and  therefore  the 
second  stage  of  labour  takes  longer,  and  rupture  of 
the  perineum  is  commoner.  Delay  in  labour  from 
this  cause  should  only  be  treated  by  patience  and 
support  of  the  patient's  strength  by  food  and  sleep. 
Although .  statistics  *  show  that  there  is  a  difference 
between  young  and  old  primiparae  in  the  duration  of 
labour,  yet  this  difference  is  not  very  great,  and  is 
not  altogether  due  to  the  state  of  the  soft  parts. 
Contracted  pelvis  and  its  consequences  are  more 
frequent  among  older  patients,  for  the  simple  reason 
that  patients  with  deformity  or  defect  in  development 
are  usually  later  in  marrying  than  the  well-built. 

The  foregoing  are  the  causes  of  slow  dilatation  of 
a  healthy  cervix.  The  diseases  which  prevent  dilata- 
tion are  so  rare  that  what  we  know  about  the  best 
way  of  treating  them  can  be  briefly  stated. 

Scar  tissue. — Part  of  the  tissue  of  the  cervix 
may  be  replaced  by  scar  tissue  from  amputation  of 
the  cervix,  or  from  cauterisation,  or  destruction  of 
tissue  in  some  other  way.  Scar  tissue  dilates  badly. 
In  such  a  case  make  numerous  small  incisions, 
radiating  from  the  os  as  a  centre.  Use  either  scissors 
or  a  probe-pointed  bistoury.  In  the  latter  case  wrap 
plaster  round  all  but  the  terminal  inch  of  the  cutting 
edge,  so  that  you  may  be  sure  of  only  cutting  the  part 
you  want  to  cut. 

*  See  Erdmann,  Arch,  fur  Oyn.,  Band  xxxix. 


Smallness   of  the    Os  Externum.      251 
Hypertrophic  elongation  of  cervix.— Organic 

disease  of  the  cervix  with  pregnancy  is  rare.  Dr. 
Roper  observed  labour  with  the  elongation  of  the 
cervix  that  accompanies  the  second  stage  of  prolapse ; 
and  it  was  long.  But  we  have  not  a  sufficient 
number  of  cases  to  show  whether  the  long  labour  was 
due  to  the  state  of  the  cervix  or  to  conditions  peculiar 
to  individual  cases.  Caesarian  section  has  been  done 
for  obstructed  labour  from  this  cause ;  but  I  think 
this  ought  not  to  be  done  again.  The  knowledge  we 
have  of  this  condition  goes  to  show  that  the  cervix 
will  dilate,  even  if  slowly. 

Smallness  of  the  os  externum. — There  are 
rare  cases  in  which,  although  the  cervical  canal  has 
been  opened  up,  the  presenting  part  has  come  down 
upon  the  os  externum,  and  labour  pains  have  lasted  for 
many  hours,  even,  it  may  be,  for  days ;  yet  the  os 
externum  remains  so  small  that  the  finger  will  not 
enter  it,  and  the  bag  of  membranes  does  not  pro- 
trude through  it ;  it  may  even  be  difficult  to  identify 
it.  There  is  no  sign  of  any  disease  to  account  for 
this.  The  inhibition  of  the  muscular  fibres  surround- 
ing the  os  externum,  which  should  be  present  at  the 
beginning  of  labour,  is  here  morbidly  absent.  We 
have  no  certain  knowledge  why :  but  it  is  supposed 
that  in  such  cases  there  may  be  congenital  smallness 
of  the  os  externum.  This  view  is  only  theoretical, 
for  no  case  has  been  recorded  in  which  the  size  of  the 
os  before  the  pregnancy  was  known.  But  it  is  plau- 
sible, as  this  course  of  events  has  only  been  seen  in 
first  labours.  The  treatment  is  to  dilate  the  os 
artificially.  First  pass  into  it  bougies,  gradually 
increasing  in  size  ;  then  the  finger  ;  then,  if  you  have 
it,  Champetier's  bag.  This  instrument  will  dilate  the 
os  to  its  full  size.  If  you  do  not  possess  this  bag,  after 
passing  one  finger  through  the  os,  pass  in  two,  then 
three,  then  four ;  and  thus  make  the  os  large  enough 
for  the  bag  of  membranes  or  presenting  part  of  the 
child  to  enter  and  dilate  it. 

Cancer. — Pregnancy  may  take  place  with  cancer. 


252  Difficult  Labour. 

When  cancer  of  the  cervix  causes  hindrance  to 
delivery,  the  disease  is  so  advanced  that  there  is 
no  difficulty  about  the  diagnosis.  The  cervix  is 
thickened,  from  the  new  growth  ;  and  the  new  growth 
is  one  which  breaks  down,  so  that  its  surface  is  ulcer- 
ated and  irregular.  Cancer  in  so  early  a  stage  that 
diagnosis  is  difficult  does  not  hinder  dilatation.  The 
course  of  the  first  stage  of  labour  depends  on  the 
hardness  or  softness  of  the  growth.  If  the  cancer 
be  soft,  easily  breaking  down,  the  cervix  will  dilate 
as  quickly  as  a  healthy  cervix.  If  it  be  hard, 
even  though  limited  to  a  part  of  the  cervix,  it  will 
greatly  hinder  dilatation.  Here  the  obstacle  to  dila- 
tation is  really  in  the  cervix. 

Treatment. — If  the  natural  bag  of  membranes  will 
not  dilate  the  cervix,  it  is  no  use  using  an  artificial 
fluid  dilator.  Take  a  probe-pointed  bistoury,  guarded 
as  described  above,  and  make  numerous  small  incisions 
in  a  direction  radiating  from  the  centre  of  the  os, 
through  the  diseased  part.  If  there  are  good  pains, 
the  bag  of  waters  will  finish  the  'dilatation.  If  by 
incisions  the  cervix  is  enlarged  to  four-fifths  of  its  full 
dilatation,  aid  the  uterine  efforts  by  forceps. 

Craniotomy  v.  Caesarian  section. — If,  notwith- 
standing incision,  the  os  does  not  yield,  or  if  the 
cancerous  mass  is  so  big  that,  although  the  rest  of 
the  cervix  is  expanded,  its  mere  bulk  obstructs  de- 
livery, and  the  child  is  living,  the  choice  lies 
between  craniotomy  and  Caesarian  section.  If  crani- 
otomy is  done,  the  child  is  sacrificed.  The  mother 
is  certain  to  die,  probably  at  latest  within  a  few 
months;  and  in  the  crushing  and  extraction  of 
the  child  the  obstructing  mass  is  sure  to  be  bruised 
and  torn,  and  may  in  consequence  get  inflamed  or 
gangrenous,  and  thus  lead  to  the  mother's  more 
speedy  death.  Taking  all  these  things  into  considera- 
tion, it  is  better,  when  cancer  of  the  cervix  forms  a 
mass  large  and  hard  enough  to  obstruct  the  birth  of 
a  living  child,  to  pei'form  Caesarian  section,  which 
will   save  the   child,  and  leave   the  cancerous  tissue 


Cancer   of   Cervix.  253 

uninjured.  The  cancerous  cachexia  often  kills  the 
child;  therefore  be  sure  that  is  is  alive  before  you 
perform  Csesarian  section.  The  risk  to  the  mother 
from  the  two  operations  is  about  the  same. 

Removal  Of  Cancer. — If  the  cancer  is  of  the 
vaginal  portion  or  cervix,  and  is  limited  to  this  part, 
as  shown  by  the  mobility  of  the  uterus,  immediately 
after  delivery  the  uterus  should  be  removed  by  the 
vagina.  Although  the  organ  is  at  this  time  large  and 
vascular,  yet  the  parts  are  so  relaxed  that  the  uterus 
can  easily  be  drawn  down  to  the  vulva,  and  the 
vessels  going  to  it  secured  by  clamps  or  ligatures. 
The  whole  uterus  should  be  removed,  because  this 
measure  is  not  more  dangerous  than  amputation  of 
cervix ;  and  if  the  cervix  is  amputated  the  os  internum 
is  replaced  by  a  ring  of  cicatricial  tissue,  which  will 
obstruct  menstruation  and  will  obstruct  delivery 
should  the  patient  again  become  pregnant.  A  uterus 
which  will  not  allow  the  safe  birth  of  a  child  is  a 
useless  annoyance  to  its  owner.  *  For  details  of 
hysterectomy,  consult  works  on  diseases  of  women. 

Cancer  at  Outlet. — Delivery  may  be  impeded  by 
cancer  of  the  vagina,  vulva,  or  rectum.  1  consider 
this  obstruction  to  delivery  here,  although  it  might 
seem  to  belong  more  properly  to  the  next  chapter, 
because  the  principles  of  treatment  are  the  same. 
If  the  growth  is  so  small  as  to  be  removable,  it 
should  be  removed.  If  not,  the  treatment  depends 
upon  its  hardness  or  softness.  If  it  is  soft,  the 
child  will  be  delivered  naturally.  If  it  is  hard, 
then  the  choice  must  be  made  between  craniotomy 
and  Cresarian  section,  guided  by  the  considerations 
pointed  out  above. 

*  See  a  Taper  by  the  Author,  Obst.  Trans.,  vol.  xx. 


.    254 


CHAPTER    XIX. 

LABOUR    COMPLICATED    WITH    TUMOURS. 

Labour  with  ovarian  tumour. — The  dangers 

which  a  patient  who  is  pregnant  and  has  an  ovarian 
tumour  incurs  when  labour  conies  on,  depend  in 
the  first  instance  upon  the  size  of  the  tumour.  Con- 
trary to  what  might  be  expected,  the  danger  with 
labour  is  rather  greater  with  small  tumours  than 
large.  The  reason  is  that  small  tumours  are  liable  to 
get  into  the  pelvic  cavity,  where  they  are  in  the  way 
of  the  child;  while  large  ones  are  too  big  to  remain 
in  the  pelvis,  and  therefore  obstruct  not  delivery. 

Natural  terminations. — Consider  first  what 
may  happen  when  a  small  ovarian  tumour  is  in  the 
pelvic  cavity,  in  the  way  of  the  child. 

1.  If  it  is  small  enough  and  the  child  not  too 
large,  the  child  maybe  driven  past  it  (Fig.  109).  The 
tumour  is  squeezed  and  one  labour  made  longer,  but 
there  may  be  no  other  ill  effect.  It  is  not  possible 
to  define  what  size  of  tumour  will  allow  this,  because 
the  event  depends  on  the  size  of  the  foetal  head  and 
of  the  pelvis,  as  well  as  on  that  of  the  tumour. 

2.  The  tumour  may  be  got  out  of  the  pelvis.  It 
may  be  pushed  up  by  the  attendant;  or  by  some 
movement  of  the  patient,  or,  as  some  think,  by  uterine 
contraction  (pulling  on  the  ligament  of  the  ovary)  it 
may  be  moved  up  ;  and  if  it  get  so  far  moved  up  that 
the  equator  of  the  head  gets  below  the  equator  of  the 
tumour,  then  the  head  will  advance  into  the  pelvis 
and  push  the  tumour  farther  aside. 

3.  If  the  tumour  be  not  moved  up  and  is  too  big 
for  the  head  to  pass  it,  the  head  being  driven  down 
on  to  it  may  rupture  the  tumour.  When  ruptured, 
the  tumour  will  generally  collapse  enough  to  let 
delivery    take    place.      Such    rupture    usually    takes 


Labour   with   Ovarian  Tumours.       255 

place  into  the  peritoneal  cavity.  The  effect  of  the 
rupture  depends  upon  the  nature  of  the  cyst  contents. 
The  fluid  of  a  tumour  that  has  not  undergone  any 
degenerative  or  necrotic  change  is  innocuous.  Au 
ovarian  tumour  has  ruptured  into  the  rectum  :  this 
is  very  rare. 


Fig-  lOit.  —Ovarian  Tumour  obstructing  Delivery.     (After  Tyler  Smith. ) 

4.  Very  often — it  is  to  be  hoped  in  most  cases — 
this  process  is  anticipated  by  the  attendant,  who 
removes  the  tumour. 

Possible  accidents. — When  the  tumour  is  in  the 
abdominal  cavity  and  is  large,  the  patient  suffers 
increased  discomfort  during  pregnancy,  from  the  great 
size  of  the  belly.  Labour  is  apt  to  be  lingering, 
because  the  distension  lessens  the  bearing-down  power 
of  the  woman.  There  is  no  special  tendency  to 
rnalpresentations. 

During  delivery,  rotation  of  the  tumour  and  twist- 
ing of  its  pedicle  are  apt  to  occur,  from  the  combined 


256  Difficult  Labour. 

effects  of  the  diminution  in  size  of  the  uterus,  the 
straining  of  the  patient  during  the  pains,  and  the 
manipulations  of  the  medical  attendant.  The  pedicle 
has  even  been  torn  through,  but  this  is  very  rare.  A 
tumour  which  before  the  birth  of  the  child  was  in 
the  abdomen  has  been  known  to  get  into  the  pelvis 
after  delivery  and  obstruct  the  exit  of  the  placenta. 

Treatment. — A  large  ovarian  tumour  situated 
in  the  abdomen  is  pretty  sure  to  have  been  dis- 
covered during  pregnancy ;  so  that  it  is  seldom  that 
this  has  to  be  dealt  with  as  a  difficulty  of  labour. 
The  best  treatment  is  to  remove  the  tumour,  even  if 
labour  has  commenced,  unless  labour  has  so  far  ad- 
vanced that  it  is  likely  that  the  child  will  be  born 
before  the  necessary  preparations  can  be  made  and 
the  operation  completed.  If  your  experience  in  ab- 
dominal surgery  is  not  large  enough  to  justify  you 
in  undertaking  this,  or  if  you  have  not  the  necessary 
skilled  assistants,  or  would  have  to  treat  the  case  in 
circumstances  unfavourable  to  the  satisfactory  carry- 
ing out  of  the  operation  and  the  after  treatment,  then 
tap  the  tumour,  and  thus  lessen  its  size. 

When  a  small  ovarian  tumour  lies  in  the  pelvic 
cavity  and  obstructs  the  passage  of  the  child,  the  first 
question  is,  Can  it  be  pushed  up  ]  If  you  can  push 
it  above  the  brim,  out  of  the  way  of  the  child,  this  is 
the  way  to  deal  with  it.  You  will  do  it  more  easily 
by  putting  the  patient  in  the  knee-elbow  position. 
You  may  have  to  put  the  whole  hand  in  the  vagina  ; 
and  if  so,  chloroform  will  be  advisable. 

If  you  cannot  push  the  tumour  out  of  the  way,  as 
may  be  the  case  if  strong  pains  are  forcing  down  the 
head,  open  the  abdomen,  lift  the  head  on  one  side 
with  the  hand,  and  then  let  an  assistant  push  the 
tumour  up  out  of  the  pelvis  with  his  hnnd  in  the 
vagina.  Then  remove  the  tumour.  If  circumstances 
make  this  impossible,  cut  into  the  tumour  with 
a  knife.  Have  ready  two  threaded  needles,  and 
put  in  a  stitch  on  each  side  of  the  cut  uniting 
the  cyst  wall  and  the  vagina 


Labour    wi  th  Fibr  oids. 


257 


A  still  better  practice  would  be  to  perform 
vaginal  ovariotomy ;  that  is,  to  incise  the  vagina 
freely,  bring  out  the  tumour,  transfix  and  ligature 
the  pedicle,  and  cut  away  the  tumour.  But  I  can- 
not  help    thinking   that  this  is  more  difficult  than 


Fig.  110.  -Labour  impeded  by  Uterine  Polypus.     {After  Tyler  Smith.) 


removing  the    tumour   by   the   abdomen :   and  it  is 
obvious  that  greater  difficulty  means  greater  danger. 

Labour  With  fibroids. — The  danger  of  fibroids 
complicating  labour  depends  in  the  first  place  on  their 
seat.  The  higher  in  the  uterus  the  tumour,  the  less 
the  danger.  When  a  tumour  is  high  up,  labour  may 
be  ended  just  as  if  there  were  no  tumour,  and 
the  presence  of  one  may  not  be  suspected.  If  the 
fibroid  be  low  down,  it  is  possible  that  it  may  not 
obstruct  delivery,  for  the  uterine  contractions  may 
pull  it  up  above  the  brim  ;  and  even  when  this  has 
not  happened,  a  fibroid  tumour  has  been  pushed 
r— 36 


258  Difficult  Labour. 

down  by  the  advancing  head  till  it  was  outside  the 
vulva,  and  thus  the  pelvic  canal  was  left  quite  free. 
Such  a  process  puts  tension  on  the  uterine  attachment 
of  the  tumour,  elongates  it  into  a  stalk,  and  may 
sever  it  (Fig.  110); 

Dangers. — If  delivery  is  not  made  possible  by 
either  of  these  methods  by  which  nature  avoids  diffi- 
culty, and  the  tumour  remains  in  the  pelvis  obstructing 
the  passage  of  the  head,  the  event  will  depend  on  the 
relative  size  of  the  tumour  and  the  child's  head,  and  on 
the  strength  of  the  pains.  If  the  tumour  is  not  too 
large  and  the  pains  are  strong,  the  child  may  be  driven 
past  it,  squeezing  and  flattening  the  tumour  against 
the  pelvic  wall  as  it  passes.  If  the  tumour  is  too  big 
to  allow  this,  and  the  labour  goes  on  unrelieved,  the 
course  is  just  as  in  obstructed  labour  from  any  other 
cause  :  the  uterus  passes  into  a  state  of  tonic  contrac- 
tion, and  either  the  mother  dies  of  exhaustion  or 
rupture  of  the  uterus  takes  place.*  Fibroids  some- 
times favour  the  occurrence  of  rupture  by  causing 
degenerative  processes  in  the  uterine  wall. 

Besides  the  direct  obstruction  to  delivery  which 
fibroids  situated  low  down  present,  they  may  in- 
directly affect  labour  unfavourably  by  causing  mal- 
pi-esentations. 

The  most  frequent  danger  to  which  fibroids  give 
rise  is  that  of  post-partum  haemorrhage,  both  primary 
and  secondary.  They  do  this  in  more  than  one  way — 
first,  the  tumour  in  its  wall  prevents  the  uterus  from 
contracting  properly,  and  thus  the  great  safeguard 
against  haemorrhage  is  impaired ;  and,  secondly,  the 
fibroid  itself  cannot  contract  at  all,  and  the  jilacenta 
may  be  implanted  on  the  fibroid  :  in  that  case,  when 
the  placenta  has  been  separated,  haemorrhage  is  only 
stopped  by  thrombosis  of  the  vessels.  Throughout 
the  lying-in  the  tumour  acts  just  as  it  does  when  the 

*  I  Lave  published  a  case  in  which  Caesarian  section  was 
required  on  account  of  the  obstruction  caused  by  a  fibroid  fixed 
in  the  hollow  of  the  sacrum.  {New  York  Journal  of  Gynaecology 
and  OLnUtrics,  June,  1893,  ]>.  484.) 


Fibroid   of   the    Cervix.  259 

patient  is  not  pregnant ;  it  is  an  irritant  to  the  uterus, 
provoking  a  flow  of  blood  to,  and  haemorrhage  from, 
the  endometrium. 

The  most  dangerous  complication  directly  resulting 
from  the  presence  of  fibroids  is  inversion  of  the  uterus. 
This  may  be  produced  in  the  third  stage  of  labour  or 
in  the  puerperal  state  in  the  same  way  as  it  is  in  the 
non-pregnant  condition,  the  tumour,  by  uterine  con- 
tractions aided  by  bearing- down  efforts,  being  driven 
down  and  dragging  the  fundus  uteri  after  it.  It  has 
been  accidentally  produced  by  the  fibroid  being  taken 
for  the  head  of  a  second  child  and  pulled  down  by 
the  attendant. 

Treatment. — If  the  tumour  obstructs  the  entry 
of  the  presenting  part  into  the  brim,  piish  it  out  of 
the  way  if  you  can.  If  you  cannot,  deliver  as  in 
labour  obstructed  by  tumours  springing  from  the 
bones.  (See  page  262. )  If  there  be  malpresentation, 
perform  cephalic  or  podalic  version.  If  there  be  post- 
partum haemorrhage,  put  your  hand  in  the  uterus 
and  see  if  you  can  remove  the  tumour.  I  have 
known  a  fibroid  thus  enucleated  with  the  hand  after 
delivery.  If  you  cannot,  treat  the  case  as  you  would 
post-partum  haemorrhage  from  any  other  cause.  If 
inversion  of  the  uterus  occur,  reduce  it  at  once ;  and 
then  enucleate  the  tumour  if  possible. 

Fibroid  of  the  cervix. — Fibroids  sometimes, 
though  rarely,  grow  in  the  cervix.  A  small  fibroid  in 
the  cervix  will  make  no  appreciable  difference  in  the 
course  of  labour.  One  of  the  size  of  a  walnut  or  larger 
will  hinder  dilatation,  partly  because  it  will  not  alter 
its  own  shape  and  will  prevent  the  part  of  the  cervix 
in  which  it  lies  from  expanding  properly,  and  partly 
because  it  will  prevent  the  head  from  entering  the  os. 

Treatment. — A  fibroid  of  the  cervix  is  accessible. 
The  treatment  is  to  remove  it.  Take  a  duckbill 
speculum  and  hold  back  the  posterior  vaginal  wall  so 
as  to  expose  the  fibroid.  Then  with  a  bistoury  make 
an  incision  over  the  whole  length  of  the  tumour, 
through  the   mucous   membrane    covering  it.      Then 


260  Difficult  Labour. 

seize  the  tumour  with  a  volsella  and  strip  the  muixms 
membrane  off  it,  and  then  separate  the  tumour  from 
its  bed  with  the  finger.  Then  rupture  the  membranes, 
to  stimulate  the  uterus  to  contract,  and  apply  a  strong 
binder,  so  that  the  head  may  come  down  on  the 
bleeding  part  and  stop  the  haemorrhage. 

Tumours  of  the  pelvic  bones.— Delivery  is 
occasionally  made  difficult  by  obstruction  from  tumours 
of  the  bones. 


Pig.  111.'— 8&cral  Exostosis. 

The  following  are  the  chief  tumours  met  with  : — 
1.  Exostoses. — Three  sorts  are  met  with  :  (a) 
Some  grow  from  the  places  where  there  is  cartilage 
— the  sacral  promontory,  the  symphysis  pubis,  the 
sacro-iliac  synchondrosis  (Fig.  111).  Sometimes  these 
outgrowths  are  sharp-pointed,  and  to  the  pelvis  so 
diseased  has  been  given  the  name  of  the  acanthopelys, 
or  the  spiny  or  thorny  pelvis.  When  the  uterus  or 
vagina  is  nipped  between  these  sharp  outgrowths 
and  the  head,  the  wall  of  the  genital  canal  may  be  cut 
or  bored  through,  and  thus  an    especial   liability  to 


Tumours  of  the  Pelvic  Bones.        261 

rupture  of  uterus  or  vagina  is  conferred  by  this 
pelvis,  (b)  Spines  are  especially  apt  to  grow  on  the 
ilio-pectineal  line  just  over  the  middle  of  the  aceta- 
bulum— that  is,  where  the  ilium  and  os  pubis  join — 
and  along  the  crest  of  the  pubes ;  and  it  has  been 
suggested  that  they  are  really  due  to  ossification  of 
the  tendon  of  the  psoas  minor  and  of  Gimbernat's 


Fig.  112.— Cancerous  Growths  from  Pelvic  Bones. 

ligament,  and  not  outgrowths  from  the  bone,    (c)  The 
pelvic  bones  may  also  be  thickened  by  periostitis. 

2.  Enchondromata. — These  and  sarcomata  are  the 
commonest  large  tumours  in  the  pelvis.  Most  of  the 
cases  described  in  the  older  literature  as  large  exos- 
toses were  probably  enchondromata.  Enchondroma 
grows  from  near  the  sacro-iliac  synchondrosis,  and 
has  a  great  tendency  to  calcification  and  the  forma- 
tion of  cysts.  A  tumour  of  this  kind  may  grow  as 
large  as  a  child's  head. 


262  Difficult  Labour. 

3.  Fibromata. — These  tumours  grow  from  the 
periosteum — most  often  from  that  of  the  iliac  crest, 
less  often  in  the  pelvic  cavity.  They  are  seldom 
large,  but  have  been  met  with  of  such  a  size  as  to 
make  delivery  impossible. 

4.  Sarcomata. — All  forms  of  sarcoma  grow  some- 
times in  the  pelvis,  especially  osteo-sarcoma,  and  may 
reach  a  great  size,  quite  blocking  up  the  pelvis.  I 
have  published  such  a  case.* 

5.  Garcinomata — Carcinomatous  nodules  in  the 
pelvic  bones  (Fig.  112)  are  always  secondary,  never 
primary.  Cases  described  as  great  masses  of  cancer 
by  old  authors  were  probably  sarcomata. 

Diagnosis. — The  diagnosis  of  tumours  of  the 
pelvic  wall  is  to  be  made  by  careful  vaginal  and  rectal 
examination.  You  will  thus  detect  that  the  tumour  is 
continuous  with  the  bones,  and  is  not  connected  with 
the  mucous  canals.  Enchondroma  is  identified  by  its 
size,  its  growing  from  near  the  synchondrosis  and  its 
unequal  consistence,  hard  spots  alternating  with  soft 
ones ;  sarcoma,  by  its  rapid  growth,  softness,  and 
vascularity ;  fibroma,  by  its  firmness,  smoothness,  uni- 
formity of  surface,  and  slowness  of  growth,  and  by  the 
absence  of  impairment  of  health.  Carcinoma  may 
be  suspected  if  the  patient  has  had  a  primary  cancer 
somewhere  else  and  is  cachectic. 

Treatment. — As  the  situation  and  amount  of 
obstruction  are  infinite  in  variety  and  differ  according 
to  the  seat  and  size  of  the  tumour,  no  general  rule 
can  be  laid  down  except  this  :  measure  with  the 
fingers  internally  the  size  of  the  pelvic  canal  at  the 
place  where  the  tumour  encroaches  on  it,  and  then 
proceed  as  in  contraction  of  the  bones  to  a  like 
degree.  The  only  difference  is,  that  as  attempts  to 
drag  a  mutilated  child  past  a  new  growth  may  in- 
flame the  growth,  and  so  endanger  life,  Caesarian 
section  should  be  undertaken  more  readily  than  in 
bony  obstruction. 

«  Lancet,  May  2,.  1891,  p.  986. 


263 


CHAPTER    XX 

RUPTURE    OF    THE    UTERUS. 

Rupture  of  uterus  apart  from  obstructed 

labour. — Rupture  of  the  uterus  has  been  referred  to 
in  foregoing  chapters  as  a  result  of  obstruction  to 
delivery.  But  rupture  of  the  uterus  is  not  always 
the  result  of  lingering  labour.  The  womb  may  be 
ripped  open  by  violence,  or  be  ruptured  by  crushing, 
as,  for  instance,  from  a  pregnant  woman  being  run 
over.  It  has  been  perforated  in  criminal  attempts  at 
abortion.  When  pregnancy  has  followed  delivery  by 
Ccesarian  section  the  uterus  has  ruptured  (even 
during  pregnancy)  at  the  site  of  the  scar.  Intersti- 
tial pregnancy  ending  in  rupture,  has  been  often 
described  as  "  rupture  of  the  uterus,"  although  it  is 
pathologically  quite  a  different  thing  from  rupture  of 
an  ordinary  pregnant  uterus.  Some  rare  cases  have 
been  reported  in  which  the  uterus  has  ruptured 
spontaneously,  that  is,  without  violence,  and  without 
disease  perceptible  to  the  naked  eye,  during  and 
at  the  end  of  pregnancy,  occurring  in  the  latter 
case  before  labour  had  apparently  commenced.  Such 
cases  seem  comparable  to  spontaneous  rupture  of 
the  heart  and  of  the  rectum.  They  have  been  at- 
tributed to  fatty,  fibrous,  or,  tubercular  degeneration 
of  the  uterus ;  but  no  morbid  change  has  been  demon- 
strated in  such  cases  ;  nor  can  we  in  the  least  predict, 
or  prevent,  or  explain  them.  Such  cases,  as  to  their 
symptoms  and  treatment,  resemble  rupture  the  conse- 
quence of  obstructed  labour.  There  are  also  some 
few  cases,  to  which  the  above  remark  also  applies, 
in  which  the  uterus  ruptures  during  short  and  easy 
labours,  without  any  obstruction. 

Rupture  from  obstructed  labour.— The  great 

majority    of   uterine    ruptures  come  from    obstructed 


264  Difficult  Labour. 

labour.  The  process  is  the  same  whatever  the 
obstruction :  whether  the  child  be  too  large  or  the 
pelvis  too  small,  or  the  child  in  a  malposition.  For 
convenience,  I  describe  it  as  happening  when  the 
head  presents.  Remember  first  what  takes  place  in 
natural  labour. 

Changes  in  the  uterus  during  natural 
labour. — In  pregnancy,  before  uterine  contractions 
begin  to  be  painful,  the  circular  fibres  around  the 
internal  os  are  inhibited ;  the  longitudinal  fibres 
of  the  uterine  body  then  pull  the  os  open,  and  thus 
the  cervix,  instead  of  being  a  narrow  canal  leading  to 
the  uterine  cavity,  comes  to  form  part  of  it.  The 
os  uteri  internum  measures,  instead  of  a  quarter  of 
an  inch  or  so  in  diameter,  nearly  four  inches  across : 
and  the  cervix,  instead  of  being  a  thick  cylinder 
enclosing  a  spindle-shaped  canal,  becomes  the  shape 
of  a  saucer,  the  external  os  being  in  the  middle  of 
the  saucer.  The  cervix  cannot  be  expanded  like 
this  without  being  thinned.  Early  in  the  first  stage 
of  labour  the  lower  segment  and  cervix  of  the  uterus 
cover  the  head  like  a  hemispherical  cap.  The  os 
externum,  even  when  only  big  enough  to  admit  the 
finger,  is  bounded  by  a  thin  edge,  quite  different  to 
the  thick  soft  cervix  of  pregnancy.  During  the  first 
stage  of  labour  the  part  of  the  uterus  above  pulls  up 
this  hemispherical  cap,  converting  it  into  a  cylinder. 
It  is  helped  to  do  this  by  the  dilating  force  of  the 
bag  of  membranes  in  the  os  externum.  In  this  pro- 
cess of  canalisation  the  part  that  has  to  stretch  the 
most,  and  therefore  to  be  thinned  the  most,  is  the 
part  near  the  external  os.  The  part  that  has  to 
stretch  and  be  thinned  the  least  is  that  just  below 
the  greatest  diameter  of  the  head.  Hence  in  a  labour 
in  which  everything  has  so  far  gone  on  without  diffi- 
culty or  accident,  the  wall  of  the  uterine  canal  would 
be  thin  near  the  os,  and  from  this  part  upwards  its 
thickness  would  gradually  increase,  without  sudden 
alteration  in  thickness  anywhere.  In  some  museum 
specimens  this  is  what  is  seen. 


The  Lower    Uterine   Segment.  265 

The  different  parts  of  the  uterus  and  their 

functions. — The  uterus,  from  the  point  of  view  of 
labour,  consists  of  three  parts. 

1.  The  part  above  the  greatest  diameter  of  the 
head,  which  does  nothing  but  contract.  As  it  contracts 
it  gets  thicker. 

2.  The  part  between  the  greatest  diameter  of  the 
head,  and  the  os  internum.  This  part  is  called  the 
lower  segment  of  the  uterus.  It  is  from  one-  to  two- 
fifths  of  an  inch  thinner  than  the  part  above,  and  in 
the  first  stage  of  labour  has  to  stretch  and  get  thinner 
still,  the  amount  of  thinning  being  greatest  at  the 
part  nearest  the  os  internum.  But  it  is  muscular 
tissue,  and  although  it  stretches  open  transversely, 
yielding  to  the  dilating  force  of  the  bag  of  mem- 
branes, yet  it  contracts  like  the  rest  of  the  uterus 
after  the  head  has  passed  through  it. 

3.  Lastly,  the  part  below  the  lower  uterine  segment 
is  the  cervix.  This  is  composed  mostly  of  fibrous 
tissue,  and  its  function  is  simply  to  dilate  and  thin ; 
it  does  not  contract.  It  is  easily  identified  by  the 
folds  of  its  mucous  membrane,  called  the  arbor  vitce 
uterince. 

The  lower  uterine  segment. — The  definition  of 
the  lower  uterine  segment  as  "  the  part  below  the 
greatest  diameter  of  the  head "  is  unsatisfactory, 
because  it  is  not  an  anatomical  definition,  but  a 
statement  of  the  relation  that,  under  certain  con- 
ditions, the  wall  of  an  organ  bears  to  its  contents. 
If  the  child  is  transverse,  for  instance,  the  state- 
ment is  no  longer  correct.  Attempts  have  been  made 
to  supply  a  better  definition.  Thus  it  has  been  defined 
as  the  part  of  the  uterus  corresponding  to  the  pelvic 
inlet.  It  generally  does  correspond  to  it,  but  not 
always.  I  think  the  best  anatomical  definition  is 
that  it  is  the  part  corresponding  to  the  line  of 
firm  attachment  of  the  peritoneum.  It  is  evident 
that  as  the  peritoneum  is  the  least  elastic  part 
of  the  uterine  wall,  its  firm  attachment  must  be 
a   considerable   hindrance   to  the   stretching   of   the 


266  Difficult  Labour. 

muscular  wall,  and  the  looseness  of  its  attachment 
low  down  is  physiologically  associated  with  the  capacity 
of  the  uterine  wall  to  stretch.  The  muscular  fibres 
of  the  lower  uterine  segment  are  differently  arranged 
from  those  of  the  upper  part  of  the  uterus  ;  they  are 
arranged  in  laminae,  like  the  leaves  of  a  book,  and 
can  be  split  asunder  with  the  handle  of  a  scalpel. 
But,  with  some  trouble,  the  upper  part  of  the  uterus 
can  also  be  shown  to  be  composed  of  laminae ;  and, 
therefore,  this  difference  is  not  one  which  enables 
us  to  draw  a  sharp  line  of  demarcation.  The  lower 
uterine  segment,  tinlike  the  cervix,  is  covered  inside 
with  decidua ;  but  at  the  end  of  pregnancy  this 
decidua  is  very  fragmentary,  and  you  may,  after 
making  sections,  fail  to  find  it. 

Condition  after  easy  labour. — After  an  easy 

labour  there  is  no  abrupt  difference  in  thickness 
between  the  cervix  and  lower  uterine  segment,  or 
between  the  lower  uterine  segment  and  the  upper 
part  of  the  uterus.  The  cervix  is  thin,  and  the  lower 
uterine  segment  gets  thicker  and  thicker  as  you  follow 
it  up.  In  the  majority  of  first  labours  the  expansion 
of  the  cervix  does  not  take  place  entirely  by  the 
process  of  thinning  described  above  ;  when  the  cervix 
is  nearly  fully  expanded  it  commonly  tears.  The  pre- 
sence of  these  tears  of  the  cervix  is  one  of  the  best 
signs  of  past  childbearing  that  we  have.  When  a 
cervix  has  once  been  torn,  its  expansion  in  subsequent 
labours  is  easier  and  quicker. 

Condition  after  obstructed  labour.— When 

there  is  obstruction  and  the  presenting  part  of  the 
child  does  not  advance  through  the  uterine  canal,  the 
upper  part  of  the  uterus  goes  on  contracting,  and  the 
lower  part  goes  on  stretching  and  getting  thinner,  till 
at  length  there  is  a  sharp  distinction  :  an  abrupt 
increase  in  the  thickness  of  the  uterine  wall  at  a 
particular  level,  and  at  this  point  a  lessening  in  size 
of  the  uterine  circumference,  so  that  this  line  projects 
as  a  ridge  internally,  and  can  be  felt  as  a  furrow 
externally  (Figs.  1 13  and  114).  This  line  has  been  called 


The  Ring  of  Bandl. 


267 


by  the  different  names  of  "  Bandl' s  ring,"  after  the 
Austrian  obstetrician  who  first  described  it,  the  "  con- 
traction ring,"  and  the  "  retraction  ring,"  the  last  name 
expressing  the  fact  that  it  is  the  lower  boundary  of 
the  retracted  part  of  the  uterus.    There  is  a  difference 


Kig.  113.  —Diagram  showing  Thickening  of  the  upper  Part  of  the  Uterus  ; 
Thinning  and  Stretching  of  the  Lower  Uterine  Segment ;  Labour 
obstructed  by  Hydrocephalus.    {After  Bandl.) 


of  opinion  as  to  the  anatomical  situation  of  this  ring, 
whether  (a)  it  coincides  with  the  os  uteri  internum, 
or  (b)  is  formed  higher  up.  Specimens  have  been 
described,  and  are  to  be  seen,  which  clearly  show  it 
(a)  just  above  the  arbor  vita? — that  is,  at  the  internal 
os.  In  other  specimens  (b)  it  seems  much  too  high 
for  this.     The  probable  explanation    appears    to    be 


268 


Difficult  Labour. 


that  (a)  the  first  part  to  be 
thinned  out  is  the  cervix ;  and 
that  (6)  if  obstructed  labour 
goes  on  after  the  cervix  has 
reached  its  utmost  thinning, 
then  the  lower  uterine  segment 
in  its  turn  thins.  If  (a)  rupture 
of  the  uterus  takes  place  before 
the  lower  segment  of  the  uterus 
has  thinned,  the  specimen  will 
show  a  retraction  ring  at  the 
internal  os.  If  (b)  the  lower 
uterine  segment  has  had  time 
to  thin,  then  the  retraction 
ring  will  be  at  the  level  of 
fii-m  attachment  of  the  peri- 
toneum. This  view  is  at 
present  hypothetical,  but  it  re- 
conciles apparently  conflicting 
observations,  and  is  supported 
by  specimens  which  show  a 
retraction  ring  at  the  level  of 
firm  attachment  of  the  peri- 
toneum, and  gradual  thinning 
of  the  lower  uterine  segment 
from  that  point  down  to  the 
os  internum,  as  if  the  thinning 
were  in  progress  (Fig.  115), 
but  not  complete. 

Mode  of  uterine  rupture. 

— When  the  head  presents  and 
the  pelvis  is  so  contracted  that 
the  head  cannot  enter  the  brim, 
if  the  membranes  rupture  be- 
fore the  dilatation  of  the  cervix 
is  complete,  the  head  may  come 
down  on  the  cervix  and  pin  it 
against  the  edge  of  the  pelvic 
brim  so  that  it  cannot  rise  up. 
This  is  especially  apt  to  occur 


2  -S 
S3  3 


UTER 1NE     RUPTUR  E. 


269 


RETRACTION 
RINC 


RETRACTION 
RIM 


NTERNAL    OS 


Fig.   115.  —  Ruptured  Uterus  showing  Retraction  Ring  at  Level  of  firm 
Attachment  of  Peritoneum ;  thinning  of  Cervix ;  gradual  thinning 
of  Lower  Uterine  Segment  from   Retraction    Ring   down   to   Os 
Internum.     (From  a  specimen  in  the  London  Hospital  Museum.*) 
a,  Firm  attachment  of  peritoneum. 

in  the  generally-contracted  pelvis,  or  in  labour  with 
a  child  of  excessive  size  ;  for  then  the  cervix  may  be 

*  Photographs  of  a  similar  specimen  by    De  Seigneux    are 
published  in  the  Arch.  f.  Gyn. ,  Band  xlii. 


270  Difficult   Labour. 

nipped  all  around  between  the  head  and  the  pelvic 
wall,  and  thus  held  down.  If  this  be  the  case,  the 
stretching  of  the  lower  uterine  segment  will  begin 
earlier  and  be  greater,  and  the  risk  of  rupture  of  the 
uterus  will  be  greater.  But  there  will  be  no  i*isk 
whatever,  with  this  state  of  things,  of  rupture  of  the 
vagina,  except  by  the  extension  of  the  tear  in  the 
uterus. 

Modes  of  vaginal  rupture. — When  the  child 
lies  transversely  the  presenting  part  does  not  fit  the 
pelvic  brim  so  accurately  as  to  hold  down  the  cervix. 
Hence,  as  the  upper  part  of  the  uterus  contracts,  the 
cervix  is  not  only  stretched  and  thinned,  but  pulled 
up,  and  thus  the  vagina  is  put  on  the  stretch.  As  in 
most  transverse  presentations  the  head  lies  in  one 
iliac  fossa  and  the  breech  lies  higher  up  in  the 
abdomen,  the  body  of  the  uterus  contracts  around  the 
breech  and  pulls  the  cervix  and  vagina  up  over  the 
head.  The  part  of  the  cervix  and  vagina  that  is  thus 
made  tense  over  the  hard  bulky  head  will  be  the  part 
exposed  to  rupture  ;  and  in  this  case  the  vagina  is  as 
likely  to  give  way  as  the  uterus.  Hence  rupture  of 
the  vagina  is  comparatively  common  in  transverse 
presentations. 

When  there  is  pendulous  belly,  especially  when 
combined  with  contracted  pelvis,  so  that  the  head 
does  not  enter  the  pelvis,  the  sinking  forward  of  the 
uterus  puts  the  posterior  vaginal  wall  so  greatly  on 
the  stretch,  while  the  uterine  contractions  force  the 
head  against  the  stretched  vagina,  that  rupture  of  the 
vagina  may  take  place.  This  mechanism  was  first 
described  by  Osiander. 

Rupture  by  injudicious  treatment.— If  in  a 

case  such  as  that  above  described — the  upper  part  of 
tlie  uterus  firmly  contracted  around  the  child,  the 
cervix  and  vagina  thinned  and  tense — you  try  to  do 
internal  version,  you  will  very  likely  rupture  the 
uterus,  either  by  the  direct  pressure  of  your  knuckles 
against  the  uterine  wall  or  by  forcing  a  projecting 
part  of  the  child  through  the  thin  cervix  or  vagina. 


Uterine  Rupture.  271 

The  formation  of  the  ring  of  Bandl  is,  therefore,  a 
contra-indication  to  version,  or  to  bringing  down  a 
leg  in  an  arrested  breech  labour. 

Direction  Of  rupture. — Rupture  of  the  uterus 
takes  place  transversely  to  the  line  of  greatest  tension. 
When  the  cervix  is  held  down  in  a  contracted  pelvis 
the  tension  is  longitudinal  and  the  rupture  transverse. 
If  it  is  made  tense  over  the  foetal  head  in  an  iliac 
fossa,  the  tension  may  be  greatest  either  in  the  length 
or  the  breadth  of  the  cervix,  and  the  rupture  conse- 
quently either  longitudinal  or  transverse.  But  these 
statements  only  apply  to  the  beginning  of  the  rupture. 
When  the  uterus  has  once  given  way  the  tear  quickly 
extends ;  and  the  direction  and  extent  of  the  rent 
depend  partly  on  the  relative  resistance  of  the  parts 
in  the  way  of  the  extension  of  the  tear,  partly  on  the 
size  and  shape  of  the  part  of  the  foetus  that  protrudes 
through  the  gap.  A  tear  beginning  in  the  cervix  may 
extend  down  into  the  vagina  or  up  into  the  contracted 
body  of  the  uterus,  either  longitudinally  or  obliquely, 
or  it  may  extend  around  the  cervix  and  nearly  sever 
the  uterus  in  half. 

Complete  and  incomplete  rupture. — The  tear 

may  extend  through  both  muscular  tissue  and  peri- 
toneum. This  is  called  complete  rupture.  The  tear  may 
go  through  the  muscular  tissue  and  not  through  the 
peritoneum.  This  is  called  incomplete  rupture.  In- 
complete rupture  is  likely  to  happen  if  the  tear  is  at 
the  side  of  the  uterus,  because  here  the  peritoneum 
Over  the  lower  uterine  segment  is  separated  from  the 
uterus  by  very  loose  cellular  tissue,  continuous  with 
that  of  the  broad  ligaments.  When  rupture  takes 
place  here,  blood  is  poured  out  into  this  cellular  tissue, 
and  then  into  that  of  the  broad  ligaments,  raising  the 
peritoneum  and  stripping  it  up  from  the  uterus. 

Rupture  of  the   peritoneum  without  the 

muscular  tissue  may  also  occur,  and  has  proved 
fatal  both  from  lueinorrhage,  and  from  peritonitis. 
But  we  know  nothing  about  either  the  causes  or  the 
symptoms  of  this  rare  form  of  rupture. 


27 2  Difficult  Labour. 

Rupture  from  disease  of  cervix.— Rupture  of 

the  uterus  may  take  place  not  from  bony  obstruction, 
but  from  disease  of  the  cervix,  such  as  cancer,  cica- 
tricial stenosis,  fibroids,  etc.,  which  prevents  its  dilating, 
and  so  produces  the  same  effects  as  the  holding  down 
of  the  cervix  between  the  foetal  head  and  the  pelvic 
wall.  Such  pathological  rigidity  of  the  cervix  is  very 
uncommon,  and,  therefore,  rupture  of  this  kind  is 
rare. 

Why  rupture  is  more  frequent  in  multipara. 

— Rupture  of  the  uterus  is  more  common  in  multiparae 
than  in  primiparse,  for  the  following  reasons.  The 
degenerative  changes  which  make  the  uterus  prone  to 
give  way  (although  we  do  not  know  precisely  what 
they  are)  occur,  as  we  should  expect,  in  uteri  that  have 
been  often  through  pregnancy  and  labour.  Malposi- 
tions of  the  head  and  malpresentations  are  more  com- 
mon, with  contracted  as  well  as  with  normal  pelves, 
in  multiparas. 

Production  by  ergot. — The  commonest  imme- 
diate cause  of  rupture  of  the  uterus  is  the  administra- 
tion of  ergot  in  obstructed  labour.  Ergot  produces 
tonic  contraction  of  the  body  of  the  uterus.  If 
obstructed  labour  be  left  to  itself,  the  conditions 
leading  to  rupture  of  the  uterus,  as  a  rule,  develop  so 
slowly  that  by  the  delay  in  delivery  ample  warning 
is  given  to  the  most  ill-instructed  accoucheur  that 
there  is  serious  hindrance.  But  ergot  hurries  on  the 
catastrophe  ;  so  that  if  you  give  ergot  in  labour 
without  ascertaining  the  size  of  the  pelvis  and  that  of 
the  child,  rupture  of  the  uterus  may  be  the  first 
intimation  that  there  is  anything  abnormal. 

Symptoms. — The  clinical  history  of  most  cases 
of  rupture  of  the  uterus  is  the  following  : — The  pains 
follow  one  another  faster  and  faster,  till  at  length  one 
pain  follows  its  predecessor  so  quickly  that  there  is 
little  or  no  interval  between  them.  If  you  examine 
the  belly  you  feel  the  hard  contracted  uterus  with  a 
furrow  running  transversely  or  obliquely  across  it.  If 
you  were  to  watch  the  progress  of  the  case  you  would 


Syatptoms  of    Uterine  Rupture.        273 

find  that  as  this  furrow  became  deeper  and  more 
abrupt  it  rose  higher  and  higher  in  the  belly.  (You 
should  not  wait  to  watch,  but  deliver  without  delay 
if  this  furrow  is  forming.)  The  hard,  contracted 
uterus  prevents  you  from  feeling  any  foetal  parts.  If 
the  uterine  contraction  is  still  intermittent  you  will 
find  that  between  the  pains  the  part  above  the  furrow 
becomes  softer,  while  that  below  remains  hard  and 
tense,  and  is  tender  when  handled.  The  patient's 
expression  becomes  anxious,  her  pulse  quicker  and 
smaller ;  her  breathing  hurried  in  proportion  to  the 
pulse,  and  shallow.  Suddenly  this  state  of  things 
changes ;  the  labour  pains  cease,  and  the  patient, 
instead  of  straining  with  all  her  might,  becomes 
collapsed.  There  is  haemorrhage  from  the  vagina,  but 
not  enough  to  explain  the  patient's  prostration.  When 
you  examine  you  find  that  the  child  is  no  longer 
pressed  into  or  on  to  the  pelvis,  but  either  has  receded 
or  can  be  pushed  back. 

These  symptoms  are  much  the  same,  whether  the 
rupture  be  complete  or  incomplete.  When  you 
examine  the  belly,  if  the  rupture  be  complete  you 
will  feel  the  limbs  of  the  child  through  the  abdominal 
walls  more  easily  than  even  in  normal  pregnancy.  If 
it  be  incomplete  you  will  feel  a  tense  swelling  rising 
out  of  the  pelvis,  but  no  distinct  foetal  parts.  Apart 
from  this  swelling,  or  the  foetal  limbs,  you  will  feel 
the  hard,  small,  firmly-contracted  uterine  body. 

When  the  child  escapes  into  the  peritoneal  cavity  the 
placenta  may  be  retained  in  the  uterus,  or  expelled  into 
the  peritoneal  cavity  after  the  child,  or  may  escape  by 
the  vagina  while  the  child  is  in  the  peritoneal  cavity. 
Delivery  of  the  placenta  before  the  child,  apart  from 
placenta  prsevia,  is  so  rare  (though  it  has  been  reported) 
that  it  should  always  make  you  suspicious  that  the 
uterus  has  ruptured. 

Events  if  not  treated. — If  after  rupture  the 

patient  be  left  alone  she  will  almost  certainly  die — 

either  quickly,  from  shock  ;  more  slowly,  from  loss  of 

blood;  or,  after  two  or  three  days,  from  peritonitis. 

s— 36 


274  Difficult  Labour. 

It  has  occasionally  happened  that  the  peritonitis  has 
led  to  the  foetus  becoming  encapsuled  in  a  cavity 
formed  by  adhesions  among  the  bowels,  and  so  the 
course  of  the  case  has  come  to  resemble  that  of  an 
extra-uterine  pregnancy  that  has  gone  to  term;  but 
this  termination  is  so  rare  that  it  cannot  in  the  least 
be  counted  on. 

Diagnosis. — The  diagnosis  of  rupture  of  the 
uterus  is  not  difficult.  The  stoppage  of  pains ;  the 
recession  of  the  presenting  part ;  the  haemorrhage ; 
the  prostration  out  of  proportion  to  the  haemorrhage  ; 
are  a  combination  of  features  not  presented  by  any- 
thing else.  The  only  difficulty  is  to  distinguish 
between  complete  and  incomplete  rupture.  The 
differential  signs  are  these.  If  the  rupture  be  incom- 
plete, the  child  will  not  have  completely  receded  ;  its 
presenting  part  will  be  still  in  the  pelvic  cavity,  while 
the  part  which  was  contained  in  the  body  of  the  uterus 
will  lie  in  a  cavity  formed  by  the  pushing  upwards 
of  the  peritoneum,  and  be  surrounded  by  effused  blood. 
Hence  on  abdominal  examination  you  feel  the  con- 
tracted uterus,  which  will  be  of  the  size  of  a  child's 
head,  or  that  of  a  cricket  ball  (according  to  whether 
it  contain  the  placenta  or  not),  and  by  the  side  of  it  a 
swelling  formed  by  the  child  covered  by  stretched 
peritoneum,  the  tension  of  which  will  prevent  the 
outline  of  the  child  from  being  clearly  made  out ;  this 
swelling  is  not  movable.  If  the  rupture  be  complete 
the  child's  presenting  part  may  or  may  not  have  com- 
pletely receded,  but  part  of  the  child,  at  least,  will  be 
free  in  the  peritoneal  cavity,  where  its  outline  can  be 
felt  with  unusual  distinctness,  and  it  can  easily  be 
moved  about.  The  contracted  uterine  body  will  be 
felt,  as  well  as  the  child,  but  may  be  behind  or  at  the 
side  or  in  front  of  it.  In  incomplete  rupture  the 
uterine  body  is  above  and  towards  one  side  of  the 
swelling  formed  by  the  child.  You  will  see  that,  while 
in  many  cases  of  complete  rupture  there  is  no  doubt 
about  the  diagnosis,  there  are  a  few  in  which  it  may 
be  difficult  to  be  certain  thai,  the  rupture  is  complete. 


Treatment  of    Uterine  Rupture.      275 

Subcutaneous  emphysema  of  the  lower  abdomen 
has  been  noticed  both  in  incomplete  and  complete 
rupture.  It  has  been  said  to  be  pathognomonic. 
There  is  no  need  to  trust  to  it,  if  it  be. 

Treatment. — This  is  of  two  kinds:  (^prophylac- 
tic, (2)  curative  The  all-important  treatment  of  rup- 
ture of  the  uterus  is  the  prophylactic.  I  can  only  briefly 
repeat  here  what  I  have  more  fully  said  in  former 
chapters.  When  obstructed  labour  has  lasted  long, 
when  the  uterus  is  in  a  state  of  tonic  contraction,  and 
when  the  ring  of  Bandl  is  felt  high  up,  immediate  de- 
livery is  absolutely  necessary.  If  the  head  is  present- 
ing in  a  favourable  position,  the  child  alive,  and  the 
pelvis  not  so  contracted  as  to  negative  the  possibility  of 
forceps  delivery,  try  to  deliver  with  forceps,  but  do  not 
protract  such  attempts.  If  the  child  be  dead,  or  if 
you  cannot  deliver  quickly  with  forceps,  perforate.  If 
the  child  be  in  a  transverse  position  do  not  try  to 
turn  :  decapitate.  If  in  a  breech  position,  use  the 
blunt  hook,  and  if  with  this  you  cannot  get  it  down, 
perforate  the  abdomen.  At  all  risks  to  the  child, 
deliver  quickly. 

It  has  been  above  stated  that  there  are  certain 
cases  in  which  rupture  of  the  uterus  takes  place  in 
easy  labour,  or  even  in  pregnancy.  As  we  know 
nothing  about  the  causes  of  such  ruptures  we  cannot 
prevent  them.  But  except  these,  which  are  very  rare, 
every  case  of  rupture  of  the  uterus  ought  to  be  pre- 
vented :  rupture  from  obstructed  labour  occurs  because 
either  the  patient  has  not  had  a  competent  medical 
attendant,  or  has  not  allowed  him  to  treat  her  properly. 
It  follows  from  this  that  it  is  exceptional  for  rupture 
of  the  uterus  to  occur  in  well-officered  lying-in 
hospitals,  or  in  private  patients  whose  means  enable 
them  to  have  the  best  attendance.  Rupture  of  the 
uterus  occurs  among  those  liable  to  be  neglected, 
and  usually  in  circumstances  unfavourable  to  the 
carrying  out  of  the  best  treatment. 

After  rupture  has  occurred  the  treatment  required 
has  three  objects  : 


276  Difficult  Labour. 

1.  To  extract  the  child  and  placenta. 

2.  To  make  the  rent  and  its  neighbourhood  quite 

clean. 

3.  Either    (a)   to   close    the   rent   accurately   by 

stitching,  or  (6)  to  provide  for  the  escape 
of  discharge  from  it. 
How  best  to  effect  these  objects  depends  on  the 
circumstances  of  the  case. 

1.  Extraction  of  child  and  placenta.— The 

child  may  be  extracted  either  (a)  through  the  vagina, 
or  (b)  by  an  opening  in  the  anterior  abdominal  wall. 
Your  choice  depends  on  the  situation  of  the  child. 
(a)  If  its  presenting  part  is  still  in  the  vagina,  and 
only  a  part  of  it  is  in  the  peritoneal  cavity,  or  if  you 
think  the  rupture  incomplete,  deliver  the  child  by  the 
vagina.  There  is  no  advantage  in  making  two  wounds 
instead  of  one.  The  obstruction  which  led  to  the 
rupture  will  prevent  you  from  delivering  without 
lessening  the  bulk  of  the  child,  and  as  the  child  is 
almost  certainly  dead,  do  this  at  once,  in  the  way 
called  for  by  the  case.  If  the  head  be  presenting, 
perforate ;  if  the  shoulder,  decapitate ;  if  the  breech, 
pull  it  down  with  a  blunt  hook,  and,  if  necessary, 
perforate  the  abdomen,  and  afterwards  the  head. 
After  delivering  the  child,  use  the  cord  as  a  guide 
to  the  placenta,  and  if  the  placenta  be  outside  the 
uterus,  use  the  cord  to  pull  it  down  gently. 

(b)  If  the  child  has  been  expelled  into  the  abdo- 
minal cavity,  so  that  you  must  pass  your  hand  through 
the  wound  and  hunt  among  the  bowels  to  get  hold  of 
its  foot,  it  is  better  to  open  the  abdomen.  If  you 
deliver  through  the  wound  in  the  genital  canal  you 
may  enlarge  the  wound,  and  so  cause  fresh  haemorrhage. 
You  may  damage  the  viscera  in  searching  for  the  foot, 
and  in  pulling  down  the  child  you  may  pull  down, 
and  perhaps  tear,  coils  of  bowel.  Open  the  abdomen 
in  the  same  way  as  for  Caesarian  section.  You  can 
then  see  what  you  are  doing.  Grasp  the  child  by 
the  foot  and  extract  it;  and  then  remove  the 
placenta 


Suture  of  Ruptured    Uterus.         277 

2.  Cleaning  the  rent. — The  next  thing  is  to 

clean  the  parts.  Much  blood  has  been  effused  :  the 
wound  surface  and  peritoneum  have  perhaps  been 
Bmeared  with  vernix  caseosa  or  meconium.  Clean 
the  parts  by  liberal  washing  with  clean  water  a  little 
hotter  than  the  temperature  of  the  body:  from  100°  to 
104°.  If  the  child  has  been  extracted  by  the  vagina, 
wash  the  parts  with  a  syringe  or  douche-tin.  Move 
the  nozzle  of  the  syringe  throughout  the  whole  length 
of  the  rent,  and  pass  it  through  the  rent  into  the 
peritoneum.  Hold  the  perineum  back  with  the  fingers 
while  doing  this,  that  the  fluid,  with  dislodged  clots, 
may  have  no  difficulty  in  returning.  To  wash 
thoroughly,  plenty  of  fluid  must  be  used ;  and  it  is 
not  safe  to  use  any  poisonous  germicide  in  large 
quantity.  It  is  essential  also  that  treatment  should 
be  prompt ;  and  it  is  better  to  wash  the  parts  im- 
mediately with  plenty  of  plain  water  than  to  wait 
to  get  sterilised  saline  solution  ready,  and  use  that 
in  limited  quantity.  Ordinary  water  from  the  tap 
may  contain  germs  of  disease  :  but  the  chances 
against  it  are  millions  to  one.  If  you  have  extracted 
by  the  abdomen,  wash  out  the  peritoneum  by  pour- 
ing water  into  it  from  a  jug. 

3.  Having  made  the  parts  as  clean  as  possible, 
now  decide  either  for  (a)  suture,  (6)  drainage. 

Suture  Of  the  rent. — (a)  Suture  is  only  pos- 
sible from  the  abdomen.  The  peritoneal  margins  of 
the  rent  must  be  sewn  together  accurately  along  the 
whole  length  of  the  tear.  If  there  are  gaps  in  the 
stitching  where  the  peritoneal  edges  are  not  brought 
into  apposition,  the  suture  might  as  well  not  have 
been  put  in  at  all.  You  will  see,  therefore,  that  to 
suture  a  ruptured  uterus  must  always  be  a  tedious 
proceeding,  requiring  a  good  light,  an  expert  assistant, 
and  a  skilled  anaesthetist.  Hence  it  is  a  mode  of  treat- 
ment that  can  seldom  be  carried  out  in  the  home  of  a 
poor  patient.  Further,  if  the  rent  be  behind,  extend- 
ing down  towards  or  into  Douglas's  pouch,  suture 
will  be  a  difficult  thing,  even  with  every  advantage 


278 


Difficult  Labour. 


I  think  that,  as  a  rule,  suture  of  the  rent  is  only 
advisable  when  the  patient  is  in  a  hospital,  and  the 
tear  on  the  anterior  surface  of  the  uterus. 

The  sutures  should  be  similar  to  those  employed  in 
Caesarian  section ;  viz.  deep  sutures  through  the  peri- 
toneum and  uterine  muscle,  not  through  the  decidua, 
about  two-thirds  of  an  inch  apart ;  and  superficial 
sutures  bringing  the  peritoneal  edges  together.     The 


Fig- 116.— Showing  extemporised  Kaised  Pelvis  Fosition. 


object  of  the  suture  is  to  get  union  of  the  peritoneal 
surfaces,  so  that  the  discharge  from  the  ragged  wound 
of  muscular  and  cellular  tissue  may  be  shut  off  from 
the  peritoneum. 

The  suturing  cannot  be  easily  done  unless  the 
patient  is  put  in  the  raised  pelvis  position.  If  the 
patient  is  lying  flat,  it  may  be  possible  to  see  the 
uterine  wound  well,  but  it  will  be  found  that  intes- 
tines bulge  forward  and  have  to  be  held  back,  or  they 
may  be  lying  in  the  wound.  In  the  raised  pelvis 
position  the  intestines  fall  towards  the  diaphragm,  so 


Drainage  in    Uterine  Rupture.        279 

that  the  uterus  can  be  seen.  If  there  be  no  table  at 
hand  which  will  support  the  patient  in  this  position, 
one  cax.\  be  extemporised  by  putting  on  the  bed  a  chair 
resting  on  its  top  rail  and  the  front  of  its  seat,  and 
pinning  a  towel  over  its  legs.  The  patient  is  then 
placed  on  the  back  of  the  chair,  her  knees  being 
supported  by  the  towel.  This  position  gives  a  better 
view  of  the  parts  concerned  than  can  be  got  in  any 
other  way  (Fig.  116). 

Drainage. — (6)  Supposing  that,  either  from  its 
position  or  from  the  circumstances,  you  do  not  think 
you  can  accurately  sew  up  the  peritoneal  wound,  it  is 
better  not  to  submit  the  patient  to  the  prolonged 
anaesthesia  and  manipulation  of  the  peritoneum  which 
this  delicate  task  involves.  The  next  best  thing  is  to 
secure  drainage.  Use  either  an  indiarubber  drainage 
tube  or  iodoform  gauze.  The  indiarubber  tube  is  the 
simpler.  Put  one  end  in  the  wound  and  let  the  tube 
conduct  the  discharge  outside  the  body,  either  by  way 
of  the  vagina  or  the  abdominal  wound.  It  is  not 
necessary  to  drain  both  ways.  Usually  the  vaginal 
route  will  be  best.  That  way  is  best  which  best 
secures  that  the  cavity  in  which  the  discharge  is 
likely  to  collect  has  the  end  of  the  drainage  tube  in  it. 

Drainage  by  iodoform  gauze  is  perhaps  better, 
but  it  is  more  difficult  to  apply.  Pack  the  wound 
with  a  strip  of  gauze,  not  so  tightly  as  to  displace 
its  margins,  but  sufficiently  to  ensure  that  the  gauze 
may  remain  in  contact  with  the  whole  surface  of 
the  wound.  This  done,  bring  the  end  of  the  gauze 
by  the  most  convenient  route,  either  the  vaginal  or 
that  by  the  abdominal  wound,  to  the  surface.  The 
threads  of  the  gauze  will,  by  capillary  attraction, 
lead  the  discharge  to  the  surface,  and  the  iodoform 
will,  if  the  wound  has  not  been  already  infected  with 
septic  matter,  prevent  its  getting  infected.  The  gauze 
may  be  left  in  for  a  week  or  even  more. 

Porro'S  operation. — It  has  been  advised  to  treat 
rupture  of  the  uterus  by  Porro's  operation.  In  rup- 
ture occurring  in  the  body  of  the  uterus  it  may  be 


280  Difficult  Labour. 

good  practice  to  amputate  the  uterus  at  the  cervix. 
The  damaged  part  is  thus  got  rid  of,  and  a  healthy 
stump  left  which  can  be  treated  in  a  surgical  way. 
But  it  is  not  such  a  good  practice  as  suturing  the 
wound  when  possible  :  and  these  are  the  cases  in 
which  the  rent  can  be  most  easily  sutured.  In  a 
rupture  involving  the  cervix  and  vagina,  if  you  cut 
off'  the  body  of  the  uterus  the  wound  in  the  cervix 
and  vagina  is  not  closed.  It  is  left  to  granulate, 
and  possibly  infect  the  system.  Porro's  operation 
here  seems  to  me  a  useless  addition  to  the  patient's 
danger.     Its  results  in  such  cases  have  not  been  good. 

Conditions  which  influence  the  result. — It  is 

not  possible  at  present  to  demonstrate  by  figures  the 
superiority  of  any  particular  method  of  treating 
rupture  of  the  uterus.  For  this  reason  I  have  often 
had  to  use  the  word  "probably."  The  success  of 
treatment  depends  on  many  other  things  besides  the 
method  which  the  operator  has  attempted  to  carry 
out :  on  the  surroundings  among  which  the  patient  is 
placed,  the  time  at  which  the  operation  is  done  (if 
postponed  for  several  hours  the  prognosis  is  worse), 
the  condition  of  the  patient,  the  skill  of  the  operator, 
the  after-treatment,  etc.  Hence  statistical  tables 
showing  percentages  of  deaths  after  this  or  that  treat- 
ment are  of  no  value  unless  we  know  more  about  the 
cases  compared  than  any  tables  that  I  know  of  tell 
us.  In  the  foregoing  I  have  described  what  seems  to 
me  the  way  likely  to  give  the  best  results.* 

The  mortality  of  cases  without  other  treatment 
than  delivery  by  the  vagina  is  about  five  out  of  six. 
Only  about  6  or  7  per  cent,  of  children  survive.  The 
modes  of  treatment  I  have  described  have  lowered  the 
mortality,  but  it  is  premature  to  say  how  much. 

*  In  a  paper  by  Merz  (Arch.  f.  Gyn. ,  Bd.  xlv.),  will  be 
found  a  collection  of  cases,  which  strengthens  the  recommenda- 
tions as  to  treatment  that  I  have  given. 


28l 


CHAPTER    XXI. 

THE    INJURIES    TO    THE   GENITAL   CANAL    IN   CHILD- 
BIRTH. 

Rupture  and  sloughing  of  the  vagina.— A 

tear  of  the  lower  segment  of  the  uterus  may  extend  into 
the  vagina  ;  or  the  vagina  may  itself  rupture  so  that 
the  child  escapes  wholly  or  in  part  into  the  abdominal 
cavity.  This  kind  of  injury  is  described  along  with 
rupture  of  the  uterus.  A  portion  of  the  vaginal  wall 
may  be  killed  by  pressure  and  may  slough.  The 
cervix  may  even  be  torn  off  all  round  like  a  ring. 
I  have  described  how  these  injuries  are  caused  in 
the  chapter  on  the  effects  of  contracted  pelvis. 

Tears  Of  the  vagina. — The  mucous  membrane  of 
the  vagina  may  be  torn.  Tears  of  this  kind  in  natural 
delivery  are  very  slight.  Great  tears  are  produced  only 
by  operative  delivery ;  such  tears  have  even  been 
known  to  involve  the  ureter. 

Their  production. — Tearing  of  the  vagina  is 
believed  to  occur  when  the  vagina  is  congenitally  small 
and  rigid,  so  that  instead  of  stretching  it  gives  way. 
Such  abnormal  fragility  is  most  likely  to  be  found  in 
elderly  primiparse.  It  is  more  likely  to  happen  with 
large  children  for  an  obvious  reason.  The  posterior 
vaginal  wall  is  more  Stretched  than  the  anterior,  hence 
tears  are  more  often  of  the  posterior  than  of  the  anterior 
wall.  The  lower  part  of  the  vagina  is  better  supported 
than  the  upper,  because  the  muscles  and  fascia?  of  the 
pelvic  floor  are  here  attached  to  it.  Hence  tears  of 
the  vagina  affect  chiefly  its  upper  part.  If  the  vagina 
is  narrowed  by  a  cicatrix,  this  cicatrix  is  apt  to  be 
torn.  But  the  great  cause  of  extensive  tearing  of  the 
vagina  is  forceps  delivery.  This  acts  in  two  ways  : 
First,  the  child  is  often  suddenly  dragged  out,  without 
giving  the  soft  parts  time  to  stretch.  Then  the  vagina 


282  Difficult  Labour. 

may  be  torn  if  the  head  is  high  up,  just  as  the 
perineum  is  torn  if  the  head  is  low  down.  Secondly, 
if  you  try  to  rotate  the  head,  the  effect  is  to  raise 
slightly  one  edge  of  the  forceps  blade  and  press  the 
other  edge  more  strongly  against  the  skull.  The 
raised  edge  may  cut  the  vagina.  This  may  happen 
without  any  conscious  attempt  at  turning  the  head 
round,  simply  from  not  holding  the  forceps  in  such  a 
manner  as  to  keep  the  blades  flat  to  the  head. 

Consequences. — These  vaginal  tears  bleed,  and 
so  may  make  the  haemorrhage  accompanying  the  third 
stage  of  labour  a  little  more  than  it  would  have  been ; 
but  they  rarely  cause  great  haemorrhage.  They  offer 
an  additional  channel  through  which  septic  poison 
may  get  access,  but  this  can  be  prevented  by  antisep- 
tics. They  generally  heal  by  granulation,  and  thus 
make  the  lochial  discharge  more  purulent  and  more 
prolonged  than  usual.. 

Treatment. — No  special  treatment  is  required 
unless  there  should  be  great  bleeding,  in  which  case 
the  rent  may  need  to  be  stitched  up.  Vaginal 
antiseptic  injections  during  the  lying-in  will  be  bene- 
ficial, as  preventing  septic  infection,  keeping  the  dis- 
charge from  becoming  offensive,  and  hastening  healing. 

Injuries  to  the  muscles  and  fasciae.— Attention 
has  been  called  lately  to  the  importance  of  injuries 
to  the  levator  ani  muscle  and  the  pelvic  fascia  during 
labour,  as  causes  of  prolapse  after  the  puerperium. 
It  is  highly  probable  that  rupture  of  fibres  in 
these  structures  from  over-stretching  does  take  place, 
permanently  weakening  them,  and  so  causing  descent 
of  the  pelvic  floor  and  womb.  But  the  accounts 
hitherto  given  of  these  injuries  are  purely  conjec- 
tural :  they  have  never  been  verified  by  dissection. 
Therefore  it  is  not  necessary  to  do  more  than  men- 
tion this  view  as  a  plausible  conjecture. 

Injuries  to  the  VUlva. — In  first  labours  the 
fourchette  is  always  torn ;  often  the  tear  extends 
farther,  and  involves  the  perineum.  As  the  head 
advances  the  parturient  canal  is  dilated  from  above 


Ruptures  of  Perineum.  283 

downwards  :  first  the  upper  part  of  the  vagina,  then 
the  perineal  body  and  vaginal  orifice,  lastly  the  vulval 
orifice.  The  perineum  is  stretched  both  from  before 
backwards  and  from  side  to  side ;  at  its  greatest 
degree  of  stretching  it  may  measure  four  or  five 
inches  from  anus  to  fourchette. 

Ruptures  Of  perineum.— When  the  perineum 
is  thus  distended,  its  thin  anterior  edge  is  its  weakest 
part,  and  therefore  this  is  the  part  most  often  torn, 
and  usually  first  torn.  Beginning  here,  the  tear 
extends  back.  How  far  back  it  goes  depends  partly 
upon  the  state  of  the  tissues  (whether  they  will  more 
readily  stretch  or  tear),  partly  upon  the  suddenness 
with  which  the  dilating  force  is  applied,  and  partly 
upon  the  magnitude  of  the  dilatation  required.  The 
larger  the  head,  the  more  suddenly  it  is  driven  through 
the  vulval  orifice,  and  the  less  distensible  the  tissues, 
the  larger  will  be  the  perineal  tear.  When  the  tear 
extends  beyond  the  fourchette  into  the  perineal  body 
it  seldom  keeps  in  the  middle  line,  although  the  tear 
in  the  fourchette  generally  begins  near  the  centre. 

Central  rupture. — That  just  described  is  the 
usual  way  in  which  the  perineum  is  torn.  There  are 
less  common  modes.  Sometimes  the  tear  begins  in 
the  vagina,  above  the  perineum,  before  the  perineum 
is  distended.  Then  the  advancing  head  comes  into  the 
tear  in  the  vagina,  widens  this,  presses  asunder  the 
muscular  and  fibrous  structures  of  the  perineal  body, 
and  comes  to  bulge  the  skin  in  the  middle  of  the 
perineum  and  finally  to  tear  it :  the  tear  beginning 
in  the  middle  of  the  perineum,  and  extending  from 
behind  forwards  to  the  fourchette,  and  from  before 
backwards  to  the  anus.  This  is  called  central  rupture 
of  tlie  perineum.  A  child  has  been  born  through  a 
central  rupture  of  the  perineum  which  did  not  involve 
the  fourchette. 

Rupture  from  above  downwards. — There  is 

another  still  rarer  mode  of  rupture  of  the  perineum 
that  I  have  once  seen.  After  the  head  had  been 
delivered  the  hand  protruded  through  the  anus,  and 


284 


Difficult  Labour. 


then  the  shoulder  came    down,  tearing  asunder   the 
perineum  from  above  downwards. 

UnUSUal  times  Of  rupture. — The  perineum  is 
generally  ruptured  during  the  passage  of  the  child's 
head.  But  not  uncommonly,  after  the  head  has  passed 
the  perineum  without  damaging  it,  the  shoulders  cause  it 
to  give  way.  This  is  especially  likely  to  happen  when 
the  child  is  very  large,  because  the  larger  the  child  the 


117.— Central  Rupture  of  the  Perineum. 
and  Lepage.) 


(After  Ribemont-Dessaignes 


larger  is  the  size  of  the  trunk  in  proportion  to  the  head. 
The  perineum  has  occasionally  been  torn  during  the 
introduction  of  the  hand  for  some  needful  manipula- 
tion, before  the  child  has  come  down  upon  it  at  all. 

Complete  and  incomplete  rupture.— From  a 

practical  point  of  view  there  are  two  kinds  of  rupture  of 
the  perineum,  no  matter  how  produced — viz.  complete 
and  incomplete.  Complete  rupture  is  that  which  goes 
through  the  sphincter  ani.  These  cases  do  not  usually 
heal  in  the  lying-in  period,  unless  they  are  carefully  sewn 


Suture  of  Ruptured  Perineum.         287 

off  straining,  while  you  press  on  the  head  so  as  to 
retard  its  progress.  The  severity  of  the  pain  which 
distension  of  the  vulva  causes  is  a  safeguard  against 
injury,  for  it  leads  the  patient  to  cry  out,  and  in 
doing  so  to  desist  from  expulsive  effort. 

Various  plans  have  been  devised  to  lessen  the 
tension  of  the  perineum.  One  is  to  press  the  sides  of 
the  perineum  towards  the  centre.  Try  to  do  this 
when  the  pei'ineum  is  tense  :  you  will  find  your  fingers 
simply  slip  over  the  skin  without  altering  its  position 
in  the  least.  The  same  remark  applies  to  the  advice 
to  press  the  hinder  part  of  the  perineum  forwards. 
Putting  the  finger  in  the  rectum  to  press  the  anus 
forwards  is  injurious  (for  you  may  injure  the  rectum), 
and  does  no  good,  for  the  perineum  must,  whatever 
its  position,  dilate  enough  to  let  the  greatest  circum- 
ference of  the  head  pass.  Pressure  directly  on  the 
perineum  was  the  plan  recommended  by  the  older 
accoucheurs ;  and  in  so  far  as  this  pressure  retarded 
the  too  rapid  advance  of  the  head  it  may  have  done 
good.  But  I  can  imagine  no  other  beneficial  effect 
from  this  practice.  Suppose  a  trouser  so  tight  that 
the  knee  could  not  be  bent  without  tearing  it,  would 
pressure  on  the  knee  prevent  the  tearing  % 

2.  Curative. — The  proper  treatment  of  ruptured 
perineum  is  to  sew  it  up  without  delay.  It  is  true 
that  many  cases  of  incomplete  rupture,  and  a  few  of 
complete  rupture,  will  heal  without  stitches,  and  that 
it  is  difficult  for  an  accoucheur  single-handed  to 
accurately  sew  up  an  extensive  rent.  But  the  stitches 
can  do  no  harm.  If  the  perineum  is  badly  stitched, 
the  patient  is  no  worse  off  than  if  it  were  not  stitched 
at  all ;  and  if  well  stitched,  not  only  is  there  less 
surface  to  discharge  and  admit  toxins,  but  the  patient 
will  be  saved  a  great  deal  of  future  annoyance. 

Put  the  patient  on  her  back  and  administer  ether 
or  chloroform.  You  cannot  in  any  other  position  see 
what  you  are  about.  When  the  patient  is  under  the 
influence  of  the  anaesthetic,  have  the  thighs  bent  up 
and  held  apart,  and  then  with  pieces  of  wool  soaked 


Difficult  Labour. 


in  1  in  2,000  biniodide  solution  thoroughly  cleanse  the 
rent,  opening  it  out  so  that  you  may  see  its  full  extent. 
Incomplete  rupture-  —  If  the  tear  is  incom- 
plete, the  best  suture  material  is  catgut.  The  advan- 
tage of  this  is  that  you  have  not  the  trouble  of  taking 
out  the  stitches,  but  can  leave  them  to  be  absorbed. 


Pig.  119.— Half-curved  Needle. 


No.  1  chromicised  gut  is  most  suitable.  Half-curved 
needles,  No.  6,  are  best  (Fig.  119).  Full-curved 
needles  are  apt  to  break  in  the  holder.  For  the 
operation  in  these  circumstances  the  ordinary  needle- 
holder  (Fig.  120)  is  better  than  Hagedorn's,  because 
with  it  you  can  put  the  needle  at  any  angle 
to  the  holder  that  you  wish.  It  is  not  necessary  to 
trim  the  ragged  surface  of  the  rent ;  it  is  better  not 
to,  for  if  you  do,  the  part  will 
bleed,  and  this  will  prevent  you 
from  seeing  well  what  you  are 
about. 

Enter  the  needle  through  the 
skin  of  the  perineum  as  close  as 
you  can  to  the  raw  surface.  Dip 
its  point  as  deeply  as  you  can,  so 
as  to  take  up  a  good  bundle  of 
the  torn  tissues.  If  you  enter  it 
on  the  torn  surface  instead  of 
through  the  skin  you  may  find  it 
cut  through  the  tissues.  If  you 
enter  it  through  the  skin  too  far 
from  the  raw  surface  you  will  get 
a  fold  of  skin  tucked  in  which  will 
p.g.  120. -Needle-bolder,  prevent  healing.  Aim  at  bringing 
it  out  through  the  vaginal  mucous 
membrane,  as  close  as  you  can  to  the  edge  of  the  raw 


Suture  of  Ruptured  Perineum.        289 

surface.  In  the  same  manner  enter  it  at  the  edge  of 
the  vaginal  mucous  membrane  on  the  opposite  side, 
and  bring  it  out  through  the  skin.  Begin  your  suture 
at  the  very  bottom  of  the  rent.  Tie  each  suture  before 
you  put  it  in  the  next.  Cleanse  with  biniodide 
solution  the  raw  surfaces  before  you  tie  each  stitch. 
Put  in  the  stitches  about  one-third  of  an  inch  from 
one  another.  After  tying  each  stitch  cut  the  ends 
short.  If  you  use  stitches  of  any  other  material 
than  catgut,  leave  the  ends  an  inch  or  more  long  : 
they  are  then  less  likely  to  prick  skin  or  mucous 
membrane,  and  are  moi-e  easily  removed. 

Complete  rupture. — Operation  here  is  more 
difficult,  as  well  as  more  important.  Should  there  be 
any  imperfection  in  your  suturing  with  catgut,  the 
operation  will  be  a  failure.  Therefore  it  is  well  to 
have  the  additional  security  of  a  strong  deep  suture 
which  will  not  be  absorbed.  Take  a  curved  needle  set 
in  a  handle,  of  size  according  to  the  extent  to  which 
the  recto-vnginal  septum  is  torn.  Enter  it  about  half 
an  inch  from  the  raw  surface,  through  the  skin  in  a 
line  with  the  recto-vaginal  septum.  Put  one  finger  in 
the  rectum  and  another  in  the  vagina :  and  guided 
by  them,  pass  the  needle  through  the  recto-vaginal 
septum,  above  the  top  of  the  rent,  and  bring  it  out 
through  the  skin  at  a  corresponding  point  on  the  op- 
posite side.  When  the  point  has  emerged,  thread  the 
needle  with  silkworm  gut,  and  withdraw  it.  Leave 
the  silkworm  gut  in  position  until  you  have  united 
the  raw  surfaces  with  catgut.  Enter  catgut  stitches 
beginning  at  the  apex  of  the  rent,  first  in  the  mucous 
membrane  of  the  rectum,  as  close  to  the  raw  surface 
as  possible.  Take  up  as  much  of  the  torn  tissue  as 
you  can,  and  let  the  needle  emerge  through  the  vaginal 
mucous  membrane,  close  to  the  raw  surface.  Enter  it 
again  through  the  vaginal  mucous  membrane  on  the 
opposite  side,  and  bring  it  out  through  the  rectal 
mucous  membrane.  Tie  it,  and  then  put  in  the  next 
stitch.  When  you  have  got  the  recto-vaginal  septum 
sutured,  the  condition  is  as  in  an  incomplete  rupture, 

T— 36 


290  Difficult  Labour. 

and  you  complete  the  suture  as  described  for  that  con- 
dition. When  all  your  catgut  stitches  have  been 
tied,  cut  the  ends  short.  Now  tie  the  silkworm  gut 
suture,  pulling  it  tight  enough  to  give  substantial  sup- 
port, but  not  to  cut  into  the  tissues.  Leave  the  ends 
of  this  about  an  inch  long.  Remove  it  at  the  end  of 
a  week.  Tie  the  patient's  legs  together,  and  let  the 
nurse  wash  out  the  rectum  night  and  morning  every 
day  with  warm  water. 

Rupture  of  vessels  without  external  wound : 
labial  hsematoma. — Sometimes  a  vein  in  the  vagina 
or  vulva  is  ruptured  without  any  external  wound  ; 
and  a  great  effusion  of  blood  into  the  cellular  tissue 
is  the  result. 

Causes. — Rupture  of  pudendal  veins,  in  the  non- 
pregnant state,  only  results  from  violence.  But 
in  pregnancy,  the  veins  returning  the  blood  from 
the  genital  organs  are  so  enlarged,  and  so  prone  to 
varicosity,  that  a  vein  sometimes  bursts  without  any 
cause  that  the  patient  knows  of.  Such  rupture  takes 
place  either  at  the  end  of  pregnancy  or  during  labour. 

The  pressure  of  the  child's  head  accounts  for  such 
rupture  during  the  second  stage  of  labour.  Rupture 
before  labour,  or  before  the  head  has  entered  the 
pelvis,  without  violence,  can,  in  my  opinion,  only  be 
accounted  for  by  the  degenerative  changes  which  ac- 
company the  varicose  condition.  Careful  observers 
(such  as  McClintbck),  have  found  that  labial  hsema- 
toma is  not  usually  met  with  in  patients  known 
to  suffer  badly  from  varicose  veins;  and  it  occurs 
most  often  in  first  pregnancies,  while  large  varicose 
veins  are  seen  in  women  who  have  had  many  children. 
The  explanation  probably  is,  first,  that  women  who 
know  they  have  varicose  veins  are  more  likely  to  keep 
recumbent  than  those  who  are  not  aware  of  it ;  and 
secondly,  that  chronic  varicosity  of  the  veins  recurring 
in  successive  pregnancies  brings  with  it  thickening 
of  their  coats  which  will  tend  to  protect  them  from 
rupture.  The  largest  varicosities  are  in  the  veins 
which  are  lowest  down,  because  (in  the  upright  posi 


Labial   Hmmatoma.  291 

tion)  they  sustain  the  greatest  pressure.  Hence  these 
spontaneous  ruptures  affect  veins  low  down,  below  the 
deep  pelvic  fascia.  Therefore  the  blood  poured  out 
travels  downwards  into  the  labium,  and  not  upwards 
towards  the  peritoneum.  The  only  cases  that  concern 
us  here  are  those  in  which  the  rupture  takes  place 
during  labour,  and  the  resulting  haemorrhage  is  large. 

Symptoms. — These  are  pain,  shock,  and  swelling 
of  the  labium.  The  pain  comes  from  the  stretching 
of  the  tissues  by  the  effused  blood  :  it  is  sudden  in 
onset,  and  severe.  The  shock  is  produced  by  the  loss 
of  blood  (for  the  blood  is  as  much  withdrawn  from  the 
circulation  as  if  it  escaped  externally)  together  with  the 
pain,  and  therefore  depends  on  the  amount  effused. 
Cases  in  which  patients  have  died  from  the  shock 
have  been  recorded.  There  is  swelling  of  the  labium 
which  may  quite  block  the  vulval  orifice,  and  thus 
obstruct  delivery.  The  swelling  is  deep  purple, 
almost  black  in  colour.  It  is  firm,  elastic,  but  not 
fluctuating,  for  by  the  time  the  swelling  has  become 
large  the  blood  has  coagulated.  It  is  not  at  all 
reducible ;  which  distinguishes  it  from  a  mass  of 
varicose  veins.  Its  colour,  sudden  formation,  and 
absence  of  fluctuation,  distinguish  it  from  an  ab 
scess.  It  does  not  gurgle  or  give  an  impulse  on 
coughing,  so  that  you  know  it  is  not  a  hernia. 

Treatment. — This  depends  upon  the  amount  of 
obstruction  to  delivery.  It  is  best  to  prevent  a 
breach  of  the  surface  if  possible.  Therefore,  if  it  be 
possible  to  deliver  without  diminishing  the  size  of  the 
tumour,  do  so.  If  it  be  so  big  that  it  is  not  possible 
for  the  child  to  pass  it,  the  only  treatment  is  to  open 
it  when  the  labour  has  passed  into  the  second  stage, 
turn  out  the  clot  and  then  deliver  the  child.  The 
opening  should  be  made  through  the  skin,  parallel 
with  the  long  axis  of  the  labium,  so  that  the  interior 
of  the  wound  can  be  readily  got  at.  If,  after  the 
child  is  born,  there  is  bleeding  from  the  cavity,  pack 
it  tightly  with  iodoform  gauze,  kept  in  position  by 
a  T  bandage. 


292 


CHAPTER  XXII. 

hemorrhage  before  delivery. 

1.  Accidental  Hemorrhage. 

Haemorrhage  before  delivery  comes  from  one 
of  three  causes. 

1.  Separation  of  the  placenta. 

2.  Disease  of  the  cervix  or  vagina. 

3.  Injury. 

The  first  cause,  separation  of  the  placenta,  is  the 
most  important.  Bleeding  from  the  second  cause  is 
seldom  great,  and  from  the  third  cause  is  rare.  Con- 
sider first  these  less  important  causes. 

Haemorrhage  from  disease  of  the  passages. 

— Pregnancy  may  occur  with  cancer  of  the  vulva,  the 
vagina,  or  the  cervix  uteri.  Such  disease  is  usually 
at  once  detected  by .  the  finger ;  for  it  does  not 
commonly  cause  haemorrhage  during  pregnancy  until 
the  disease  is  so  advanced  that  diagnosis  is  not 
difficult.  Haemorrhage  may  occur  from  an  erosion — 
that  is,  a  flat  adenomatous  growth — on  the  cervix ;  or 
from  a  mucous  polypus  (a  stalked  adenoma)  or  a 
fibroid  of  the  cervix.  These  causes  are  important, 
because  cases  in  which  menstruation  is  said  to  have 
occurred  during  pregnancy  are  most  probably  of  this 
nature.  The  treatment  of  these  diseases  when 
associated  with  pregnancy  does  not  fall  within  the 
scope  of  a  work  on  "difficult  labour,"  but  it  is  needful 
to  mention  them  among  the  causes  of  haemorrhage. 

Bleeding  from  injury.— During  pregnancy  the 
blood-vessels  of  the  genital  organs  are  enormously 
bigger.  Hence  if  a  pregnant  woman  near  term  is 
wounded  in  the  genitals  (as  sometimes  happens, 
for  instance,  from  falling  so  that  this  part  meets 
something  sharp,  or  from  sitting  on  a  broken  utensil) 
a  large  vein  will  probably  be  opened  and  the  bleeding 


Accidental  Hemorrhage.  293 

be  terrific  ;  it  generally  kills  the  patient  before  a 
doctor  can  be  fetched.  The  way  to  stop  such  bleeding 
is,  first,  to  place  the  patient  recumbent,  then  press  on 
the  bleeding  point  with  the  fingers,  clear  away  clots, 
and  adjust  a  firm  pad  to  keep  up  pressure  on.  it. 
These  cases  are  fortunately  rare. 

The  usual  kind  of  antepartum  haemor- 
rhage.— The  great  cause  of  ante-partum  haemorrhage 
is  separation  of  the  placenta.  Cases  of  this  kind  of 
haemorrhage  were  divided  by  Rigby  into  two  classes, 
which  he  distinguished  by  the  names  of  accidental  and 
unavoidable  haemorrhage. 

Definitions. — If  the  placenta  is  implanted,  as  it 
should  be,  on  the  upper  or  middle  zone  of  the  uterus, 
the  child  is,  as  a  rule,  born  before  the  placenta  is 
detached.  In  this  case  separation  of  the  placenta  is 
no  necessary  part  of  the  process  of  delivery,  but  is  an 
unfortunate  accident,  which  we  would  prevent  if  we 
knew  how.  Hence  haemorrhage  of  this  sort  is  called 
accidental  haemorrhage. 

If  the  placenta  is  implanted  over  the  lower 
segment  of  the  uterus,  the  part  which  must  expand 
and  be  changed  from  a  hemisphere  into  a  cylinder  to 
let  the  child  pass,  it  will  be  clear  that  the  child  cannot 
be  born  without  separation  of  the  placenta.  Hence 
Rigby  called  this  unavoidable  hemorrhage.  The 
condition  is  placenta  praivia. 

Accidental  haemorrhage  means  haemorrhage 
from  uterine  vessels  opened  by  the  premature  detach- 
ment of  a  normally  situated  placenta  (Fig.  121). 

Etiology. — We  know  very  little  of  the  causes  of 
such  detachment :  not  enough  to  foretell  or  prevent 
its  occurrence.  Sometimes  it  follows,  and  therefore 
appears  as  if  it  were  caused  by,  some  accident,  such 
as  a  fall,  a  blow,  or  a  strain.  But  in  many  cases 
there  is  no  such  history  :  in  many  in  which  there 
is  such  a  history  the  accident  has  been  a  very  slight 
one,  and  in  others  the  connection  in  time  is  not 
very  close.  J.  Ranisbotham  remarks :  "  The  attack 
rarely  follows  the  immediate  application  of  a  supposed 


294  Difficult  Labour. 

cause  ;  a  lapse  of  some  time  usually  intervenes."  On 
the  other  hand,  cases  are  known  in  which  pregnant 
women  have  sustained  very  great  violence  without 
any  detachment  of  placenta  taking  place.  We  do 
not   know    what    are    the    causes   which   make   the 


Fig.  121. — Accidental  Hemorrhage. 

placenta   in   some   women   veiy   easily   detached,  in 
others  not  so. 

In  some  cases  it  has  closely  followed  a  strong 
emotion.  Two  theoretical  explanations  of  this  have 
been  given.  One  is  that  the  emotion  causes  a  spas- 
modic contraction  of  some  muscular  fibres  at  the  place 
where  the  placenta  is  attached,  by  which  the  utero- 
placental vessels  at  that  spot  are  torn  through.  The 
other  is  that  the  emotion  causes  a  flow  of  blood  to  the 
uterus,  so  that  the  sudden  tension  of  the  vessels  bursts 
open  one  or  more  of  them.  Both  these  views  are 
purely  theoretical,  for  no  one  has  ever  seen  or  in  any 


Causes  of  Accidental  Hemorrhage.    295 

way  proved  either  the  spasmodic  contraction  or  the 
afflux  of  blood.  If  they  are  accepted  as  sufficient  for 
the  time,  in  the  absence  of  better  knowledge,  it  must 
be  admitted  that  we  have  no  knowledge  whatever  why 
emotion,  to  which  all  women  are  liable,  should  cause 
haemorrhage  in  only  a  few. 

A  very  small  haemorrhage  may,  by  the  uterine 
contractions  of  pregnancy,  become  the  cause  of  ex- 
tensive detachment  of  the  placenta  and  great  haemor- 
rhage. When  a  vessel  is  torn  a  little  blood  escapes 
between  the  placenta  and  the  uterine  wall.  When  a 
uterine  contraction  comes  on,  and  the  placenta  is 
compressed  between  the  bag  of  waters  and  the  uterine 
wall,  the  effect  would  be,  if  not  counteracted,  to  squeeze 
out  flat  this  little  effusion  of  blood.  If  the  utero- 
placental vessels  surrounding  the  effusion  are  weak, 
the  blood  will  be  squeezed  into  a  flat  layer,  will  make 
its  way  between  uterus  and  placenta,  tearing  through 
vessels  in  doing  so,  and  then,  when  the  uterus  relaxes 
again,  these  newly-torn  vessels  will  bleed,  and  thus  a 
little  bleeding  becomes  the  cause  of  a  great  one.  This 
explains  why  haemorrhage  does  not  always  immediately 
follow  what  seems  to  have  been  its  cause. 

In  some  cases  accidental  haemorrhage  comes  on 
during  sleep.  In  such  cases  we  cannot  flatter  our- 
selves that  we  have  discovered  its  cause. 

There  is  no  doubt  as  to  one  fact — viz.  that  this 
kind  of  haemorrhage  is  much  commoner  in  women  who 
have  had  raany  children  than  in  those  pregnant  for 
the  first  time.  This  points  strongly  to  the  conclusion 
that  the  cause  of  the  haemorrhage  will  be  found  in 
conditions  of  the  uterus,  or  of  the  system  generally, 
produced  by  childbearing.  The  probability  is  that  the 
chief  cause  of  accidental  haemorrhage  is  disease  of  the 
decidua.  But  at  present  we  do  not  know  of  any 
morbid  change  in  the  decidua  which  is  special  to 
accidental  haemorrhage,  or  which  has  even  been 
frequently  found  with  it. 

Disease  of  the  blood  or  blood-vessels  may  lead  to 
haemorrhage    from   the  uteroplacental  blood-vessels, 


296  Difficult  Labour. 

just  as  from  blood-vessels  anywhere  else.  There  is  no 
doubt  that  Bright's  disease  leads  to  haemorrhages  into 
the  placenta.  From  this  fact  it  is  reasonable  to  expect 
that  accidental  haemorrhage  would  be  common  in 
Bright's  disease,  but  it  has  not  yet  been  demonstrated 
that  it  is. 

Other  diseases  which  cause  haemorrhage  elsewhere 
have  been  stated  to  cause  accidental  haemorrhage  from 
the  placental  site,  such  as  small-pox,  scarlet  fever, 
acute  atrophy  of  the  liver,  leukaemia.  It  is  reasonable 
to  expect  that  these  conditions  would  do  so,  but  they 
are  such  rare  complications  of  pregnancy  that  their 
effect  on  it  cannot  yet  be  said  to  be  proved. 

Diagnosis. — When  the  bleeding  is  external,  acci- 
dental haemorrhage  has  to  be  distinguished  from  (a) 
bleeding  due  to  disease  or  injury  of  the  vulva,  vagina, 
or  cervix ;  and  (b)  placenta  praevia.  The  former 
causes  (a)  will  be  perceived  at  any  stage  of  the  labour 
by  examination  of  the  cervix  and  vagina.  Accidental 
haemorrhage  cannot  be  distinguished  from  placenta 
praevia  until  the  os  uteri  will  admit  the  finger.  Then, 
instead  of  the  rough  spongy  placenta,  you  feel  the 
smooth  membranes.  The  relation  of  pain  to  haemor- 
rhage is  discussed  in  chapter  xxiii. 

Concealed  accidental  haemorrhage.— If  the 

attachment  of  the  placenta  to  the  uterus  be  firm,  the 
blood  may  be  confined  within  the  placental  area.  It 
may  push  the  placenta  inwards,  making  it  into  a  cup 
the  hollow  of  which  looks  to  the  uterine  wall,  and 
bulge  the  uterine  wall  outwards,  so  as  to  make  a  boss 
that  can  be  felt  on  the  surface  of  the  uterus. 

But  it  is  seldom  that  the  placenta  is  attached  so 
firmly  that  a  local  swelling  of  this  sort  is  formed. 
Generally  the  blood  breaks  through  at  one  part  all  the 
utero-placental  vessels  that  are  in  its  way,  and  escapes 
between  the  membranes  and  the  uterine  wall,  separating 
the  membranes  and  thus  making  its  way  to  the  os, 
and  flowing  out  into  the  vagina. 

In  some  cases  the  uterus  does  not  conti-act  strongly 
enough  to  force  the  blood  towards  the  os,  and  the 


Concealed  Accidental  Hmmorrhage.    297 

blood,  therefore,  may  lie  in  considerable  quantity 
between  the  membranes  and  the  uterus,  and  not  escape 
outside  at  all.  It  is  possible  that  the  membranes  may 
be  so  firmly  attached  round  the  os  uteri  as  to  prevent 
the  blood  from  flowing  out.  If  labour  has  begun,  the 
head  may  be  so  pressed  down  upon  the  cervix  uteri  as 
to  prevent  the  blood  from  escaping  outside.  There  is 
yet  another  possibility.  The  bleeding  may  bulge  the 
membranes  inwards  so  much,  and  put  so  much  pressure 
upon  them,  that  they  may  rupture  and  the  bleeding 
take  place  into  the  cavity  of  the  amnion.  From 
these  different  causes  bleeding  may  be  copious  and  yet 
none  of  the  blood  escape  outside.  This  is  called 
concealed  accidental  haemorrhage. 

Diagnosis  of  concealed  accidental  haemor- 
rhage.— Here  there  may  be  either  no  flow  of  any- 
thing from  the  vagina,  or,  after  the  effused  blood  has 
coagulated  in  the  uterus,  the  serum  may  gradually 
trickle  out.  But  as  no  blood  flows  out  the  diagnosis 
may  not  at  first  be  made.  In  a  well-marked  case  it 
is  not  difficult.  (1)  The  loss  of  blood  blanches  the 
patient.  (2)  Loss  of  blood  makes  the  pulse  small,  quick, 
and  weak.  When  a  patient  shows  evident  signs  of  great 
loss  of  blood,  without  any  external  haemorrhage,  you 
at  once  think  that  there  must  be  internal  bleeding. 
(3)  The  bleeding  into  the  womb  distends  it.  Hence 
the  womb  is  larger  than  it  was,  it  feels  hard  and  tense, 
and  it  is  rounded,  because  the  spherical  shape  is  that 
which  holds  most  within  a  given  compass,  and 
therefore  under  tension  the  uterine  cavity  tends  to 
become  round.  The  uterus  will  yield  to  gradual 
stretching,  as  in  twin  pregnancy  or  dropsy  of  the 
amnion,  but  it  does  not  tolerate  sudden  stretching. 
Therefore,  (4)  the  tension  of  the  womb  causes  great 
pain,  often  described  as  a  continuous,  stretching,  tear- 
ing feeling ;  and  this  pain  prostrates  the  patient  to 
a  degree  even  greater  than  the  loss  of  blood  would 
account  for.  These  signs,  the  enlargement  and  hard- 
ness of  the  womb,  and  the  pain  in  it,  tell  you  that  the 
bleeding  is  into  the  uterus. 


298  Difficult  Labour. 

Treatment. — Nature  stops  haemorrhage  from 
the  placental  site  by  (1)  compression  of  the  vessels  by 
uterine  contraction  ;  (2)  clotting  of  the  blood  in  the 
vessels,  and  organisation  of  the  clot.  As  we  cannot 
possibly  get  at  the  bleeding  vessels  in  accidental 
haemorrhage,  what  we  have  to  do  is  to  help  the 
natural  cure. 

The  amount  of  uterine  contraction  necessary  to 
close  the  vessels  and  bring  about  thrombosis  depends 
upon  the  size  of  the  vessels.  When  the  whole 
placenta  is  separated,  as  it  is  after  labour,  the  vessels 
laid  open  are  so  large  that  nothing  short  of  complete 
uterine  retraction  is  enough  to  close  them.  But  if,  as 
is  not  very  uncommon,  only  a  few  small  vessels  are 
torn  across,  the  intermittent  uterine  contractions  that 
go  on  during  pregnancy  may  compress  them  enough  to 
bring  about  thrombosis.  The  treatment  of  accidental 
haemorrhage,  therefore,  depends  first  upon  its  amount. 

Slight  haemorrhage. — If  the  amount  of  blood 
lost  is  trifling,  the  patient's  pulse  not  notably 
quickened  or  her  mucous  membranes  blanched,  it 
will  be  enough  to  keep  her  for  a  few  days  recumbent. 
When  the  patient  is  lying  down  the  circulation  is 
slower  and  therefore  the  liability  to  renewal  of  the 
haemorrhage  less.  Forbid  alcohol,  because  it  dilates 
the  arteries  and  thus  favours  haemorrhage.  Give 
5  grains  of  gallic  acid  three  times  a  day,  to  contract 
the  small  vessels.  Give  with  it  half  a  fluid  drachm  of 
the  liquid  extract  of  ergot.  This  will  make  the  uterus 
and  its  arteries  contract,  and  uterine  contraction  is 
the  natural  means  of  stopping  uterine  haemorrhage. 
If  the  patient  is  frightened  and  anxious  about  her 
condition,  or  of  so  active  a  temperament  that  you. 
doubt  if  she  will  rest  even  though  recumbent,  give 
also  gr.  xv  of  sodium  bromide  to  lessen  reflex  irrit- 
ability. This  mode  of  treatment  is  only  safe  if  the 
haemorrhage  is  trifling. 

Great  haemorrhage. — If  the  haemorrhage  is 
copious  the  condition  is  highly  dangerous  and  the 
patient  is  not  safe  till  she  has  been  delivered  and  the 


Treatment  of  Accidental  Haemorrhage.   299 

uterus  is  retracted  afterwards.  The  treatment  there- 
fore is  to  get  the  uterus  contracted,  retracted,  and 
emptied,  as  quickly  as  possible  without  injury. 

1.  Before  full  term. — The  quickest  way  of 
reducing  the  size  of  the  pregnant  uterus,  and  thus  en- 
abling it  to  contract,  is  by  rupturing  the  membranes. 
The  disadvantage  of  this  is,  that  we  lose  the  bag  of 
membranes  as  a  dilator.  But  if  the  pregnancy  has 
not  reached  term  the  child  will  be  small,  and, 
unless  it  be  lying  transversely,  its  head  or  breech 
will  come  down  into  the  cervix  and  dilate  it  nearly 
as  well  as  the  bag  of  membranes,  and  much  better  than 
the  larger  and  harder  head  at  full  term.  The  uterus 
can  be  further  stimulated  by  the  pressure  of  a  binder 
tightly  applied.  When  uterine  retraction  has  begun, 
the  best  way  of  hastening  it  is  by  giving  ergot.  Ergot 
ought  only  to  be  given  when  it  is  quite  certain  that 
there  is  no  obstruction ;  and  in  the  case  of  premature 
delivery  we  may  be  generally  certain  that  this  is  so. 
The  period  of  pregnancy  up  to  which  it  is  proper  to 
give  ergot  must  be  judged  of,  not  by  months,  but  by 
the  size  of  the  child.  If  the  uterus,  after  the  waters 
have  escaped,  does  not  reach  higher  than  half-way 
between  the  umbilicus  and  the  ensiform  cartilage,  and 
the  head  or  breech  present,  it  is  quite  safe  to  give 
ergot,  unless  there  is  great  narrowing — either  from 
pelvic  deformity,  tumour,  or  disease — of  the  pelvic 
canal.  Ascertain  first  the  position  of  the  child,  and  if 
transverse  correct  it  by  abdominal  manipulation. 

In  short,  in  accidental  haemorrhage  occurring  before 
the  uterus  reaches  higher  than  half-way  between  the 
ensiform  cartilage  and  umbilicus,  see  that  the  canal 
is  not  contracted,  and  that  the  child's  long  axis* 
corresponds  to  that  of  the  uterus.  These  conditions 
being  present,  rupture  the  membranes,  put  on  a  firm 
binder,  and  give  ergot. 

2.  At  term;   cervix   not   dilated. — If   the 

patient  is  nearer  term  and  dilatation  of  the  cervix  has 
not  begun,  if  you  rupture  the  membranes  the  large 
hard  head  will  be  an  inefficient  dilator,  and  the  first 


300  Difficult  Labour. 

stage  of  labour  will  be  long.  Dilate  the  cervix 
with  Hegar's  dilators,  or  the  finger,  till  it  will 
admit  two  fingers.  Then  rupture  the  membranes. 
This  will  diminish  the  uterine  contents,  and  allow 
the  uterus  to  contract  better.  This  done,  put  in 
Champetier  de  Ribes's  bag.  This  will  supply  the 
place  of  the  bag  of  waters  as  a  dilator,  will  take  up 
less  room,  and  by  its  pressure  on  the  lower  uterine 
segment  will  excite  reflex  uterine  contraction.  You 
thus  get  the  advantages  of  rupture  of  membranes 
without  the  disadvantages.  Put  a  strong  binder  over 
the  uterus  and  fasten  it  as  tightly  as  possible.  Tell 
the  nurse  to  tighten  it  if  it  gets  loose.  This  will 
help  to  force  the  dilating  bag  into  the  cervix  and  may 
possibly  press  directly  upon  the  part  of  the  uterine 
wall  in  which  run  the  bleeding  vessels.  When  the 
dilatation  is  complete,  stimulate  the  uterus  to  con- 
tract if  necessary,  and  if  uterine  action  be  not  strong 
enough  to  expel  the  child  quickly,  use  forceps,  pull  on 
the  breech,  or  bring  down  a  foot,  as  the  position  of  the 
child  indicates. 

3.  First  stage  in  progress. — The  os  may  be 

dilated  enough  to  admit  two  fingers.  If  so,  perform 
bipolar  version  and  bring  down  a  foot.  The  half- 
breech  will  be  a  good  dilator,  and  the  letting  off  of 
the  waters  and  bri  tiging  down  of  the  leg  will  favour 
uterine  contraction. 

4.  Cervix  dilated. — The  os  uteri  may  be  dilated 
to  four-fifths  of  its  full  size.  Rupture  the  membranes 
and  apply  forceps ;  or  bring  down  a  leg,  according  to 
the  position  of  the  child. 

5.  In  concealed  accidental  haemorrhage  the 

first  thing  to  be  done  is  to  relieve  the  excessive  tension 
within  the  womb.  Therefore  separate  the  membranes 
as  far  round  the  os  as  your  finger  will  reach,  to  help 
the  escape  of  the  blood  which  is  probably  between  the 
membranes  and  the  uterine  wall,  and  having  done 
this,  rupture  the  membranes.  Then  proceed  as 
you  would  do  in  accidental  haemorrhage  of  the 
ordinary  kind. 


Trea  tment  of  Acer  dent  a  l  Hazmor  rha  ge.    301 

Caesarian  Section. — Accidental  haemorrhage 
has  been  treated  by  Caesarian  section,  and  might  be 
by  Porro's  operation.  This  stops  the  haemorrhage. 
When  the  haemorrhage  is  great  and  the  womb  cannot 
be  got  to  contract  (for  these  are  the  cases  that 
die),  but  all  necessary  preparations  can  be  made  and 
efficient  assistance  had,  this  will  be  the  best  course. 
But  not  many  lives  are  likely  to  be  saved  in  this 
way,  for  Caesarian  section  is  an  operation  for  which 
preparations  have  to  be  made ;  while  the  course  of 
bad  cases  of  accidental  haemorrhage  is  rapid. 

Haemorrhage  in   twin   labours. — Accidental 

haemorrhage  may  be  caused  mechanically  in  twin 
labours,  from  the  diminution  in  size  of  the  uterus 
following  the  birth  of  the  first  twin  leading  to  such 
shrinking  of  the  placental  site  as  partly  to  detach 
the  placenta.  Such  haemorrhage  is  hardly  ever  in 
itself  important,  because  when  the  passages  have  been 
dilated  by  the  first  child,  the  second  can  be  quickly 
delivered,  and  haemorrhage  is  stopped,  or  ceases  to 
come  under  the  term  "  accidental     haemorrhage. 

Plugging  the  vagina  has  been  recommended  for 
accidental  haemorrhage,  as  it  has  been  for  most  kinds 
of  haemorrhage.  The  only  way  in  which  it  does  good  is 
by  irritating  the  cervix  and  so  stimulating  the  uterus  to 
contract.  It  is  a  clumsy  and  painful  way  of  doing  this. 
The  remarks  at  page 3 19  on  plugging  for  placenta praevia 
apply  also  to  plugging  for  accidental  haemorrhage. 

Liability  to  post-partum  haemorrhage. — In 

haemorrhage  before  delivery,  remember  that  the  weak- 
ening of  the  patient  by  loss  of  blood  makes  it  more 
likely  that  there  will  be  post-partum  haemorrhage,  and 
makes  the  patient  less  able  to  stand  the  effect  even  of 
moderate  loss  of  blood  after  delivery.  Therefore  in  any 
case  of  haemorrhage  before  delivery  be  very  careful  to 
watch  for  and  counteract  the  slightest  tendency  to 
post-partum  haemorrhage.  Observe  the  condition  of 
the  uterus  for  at  least  an  hour  after  delivery,  knead- 
ing it  the  moment  it  seems  inclined  to  become  relaxed. 
Give  ergot  immediately  after  the  child  is  born. 


3°* 


CHAPTER    XXIII. 

HEMORRHAGE    BEFORE   DELIVERY. 

2.  Placenta  PRiEViA. 

Definitions. — The  placenta  is  prcevia  when  if  lien 
over  the  lower  segment  of  the  uterus :  that  is,  the 
part  of  the  uterus  which,  before  labour,  is  a  hemisphere, 


Fig.  122.— Diagram  to  show  the  "Dangerous"  or  "Cervical"  Zona. 
(After  R.  Barnes.) 

(This  diagram  is  taken  from  Barnes  without  alteration  :  but  I  know  of  no 
foundation  in  fact  for  the  statement  it  implies,  that  the  implantation  of 
the  placenta  on  the  "equatorial  zone"  is  associated  either  with  tediout 
labour  or  with  post-partum  flooding.) 


and  during  labour  becomes  a  cylinder.  In  protracted 
labour  the  distinction  between  the  lower  segment  and 
the  contracting  part  of  the  uterus  becomes  anatomically 
evident.     Before  labour  there  is  no  evident  boundary. 


Placenta  Previa. 


3°3 


R.  Barnes  has  happily  called  the  lower  segment  of 
the  uterus,  looked  at  as  a  site  for  the  placenta,  the 
"dangerous  zone  "  (Fig.  122).  This  zone  is  roughly 
bounded   by  a  circle,  with   the    os   internum   as  its 


Fig.  12a— Placenta  Prsevia. 


centre,  and  a  radius  cf  about  three  inches  measured 
from  the  os  externum. 

Central  placental  previa  is  when  the  placenta  is  so 
implanted  that  the  finger  in  the  os  uteri  feels  placental 
tissue  all  round  (Fig.  123). 

Partial  or  lateral  placenta  prwvia  is  when  the 
placenta  covers  the  margin  of  the  os  at  one  part  only, 
and  elsewhere  the  finger  comes  into  contact  with  the 
Bmooth  membranes. 

Marginal  placenta   prcevia  is  when  the  placenta 


304  Difficult  Labour. 

does  not  cover  the  os  uteri  at  all ;  but  a  part  of  the 
placenta  is  implanted  on  the  lower  uterine  segment. 

The  placenta  is  never  implanted  on  the  cervix.  A 
few  cases  have  been  reported  in  which  the  placenta 
has  seemed  to  be  attached  to  the  cervix ;  but  such  an 
occurrence  is  so  rare,  and  so  opposed  to  physiology, 
that  it  is  probable  the  supposed  examples  of  it  have 
been  misinterpreted. 

Etiology. — A.  Theory.  1.  When  the  ovum  passes 
into  the  uterus  from  the  Fallopian  tube  it  ought  to 
be  received  by  the  decidua  at  the  upper  part  of  the 
uterine  cavity.  If  it  is  not,  the  ovum  is  carried  by 
the  flow  of  the  secretions  downwards,  towards  the 
internal  os.  If  it  gets  caught  on  its  way  out  by  the 
decidua  close  to  the  os  uteri,  the  decidua  serotina  will 
be  formed  at  this  point,  and  the  placenta  will  be 
■prcevia. 

This  view  is  theoretical,  because  no  one  has  ever 
seen  what  happens.  But  on  this  theory,  it  will  be 
evident  that  there  are  two  conditions  which  favour 
the  production  of  placenta  prsevia.  One  is  an  im- 
perfect decidua,  so  that  the  ovum  is  not  received 
as  it  ought  to  be.  The  other  is,  abnormal  uterine 
contraction,  causing  movement  of  the  uterine  con- 
tents, and  thus  moving  the  ovum  about  in  utero. 

2.  Cases  have  been  described  in  which  the  nor- 
mally implanted  ovum  has  been  displaced  from  its 
attachment,  but  not  separated ;  and  has  come  to  hang 
by  a  stalk  of  decidua  serotina  down  towards  the  os 
uteri,  and  project  into  the  cervical  canal;  and  at  least 
one  case  has  been  described*  which  seems  to  show 
that  an  ovum  so  displaced  may  become  attached  to 
the  uterus  lower  down,  and  there  develop;  the 
placenta,  from  its  low  site,  becoming  prcevia. 

3.  Specimens  have  been  shown  which  seem  to 
support  the  following  view.f  If,  from  imperfect  for- 
mation of  the  decidua  at  the  top  of  the  uterus,  the 
chorionic  villi  inserted  into  the  decidua  serotina  do 

*  Muller,  "Placenta  Prsevia,"  p.  160. 

t  See  Ealtenbach,  Zeit.  fw  Geb.  und  Ctyn.,  Bd.  xviii. 


Causes  of  Placenta  Previa.  305 

not  adequately  nourish  the  ovum,  the  villi  at  the 
opposite  pole  of  the  ovum,  that  corresponding  to  the 
decidua  reflexa,  may,  instead  of  becoming  atrophied, 
grow  through  the  reflexa,  and  implant  themselves  on 
the  decidua  vera  around  the  os  uteri.  Hence  it  has 
been  proposed  to  adopt,  as  a  definition  of  placenta 
prsevia,  placenta  developed  over  the  lower  pole  of  the 
reflexa.  But  the  specimens  illustrating  these  two 
theories  are  too  few  as  yet  to  be  conclusive. 

B.  Facts. — Placenta  prsevia  is  met  with  about  once 
in  1,000  cases.  It  is  more  common  in  multipara?,  and 
in  the  later  years  of  the  childbearing  period.  The 
inference  is,  that  it  is  due  to  changes  in  the  uterus 
produced  by  childbearing.  It  is  said  to  be  especially 
common  in  women  in  whom  successive  pregnancies 
have  followed  one  another  very  quickly.  The  facts 
published  in  support  of  this  statement  are  very  few  ; 
but  as  women  who  have  many  children  generally  have 
them  fast,  it  seems  probably  true.  Repeated  mis- 
carriages, syphilis,  leucorrhcea,  lacerations  of  the  cer- 
vix, over-exertion,  mental  and  physical  shocks,  have 
all  been  enumerated  among  the  causes  of  placenta 
previa,  but  without  any  evidence.  Enlargement  of 
the  uterine  cavity  has  been  said  to  produce  it  mechani- 
cally, by  there  being  more  room  for  the  ovum  to  wander 
about,  and  so  more  risk  of  its  getting  into  the  wrong 
place.  The  diameter  of  the  ovum  is  T^  of  an  inch, 
whilst  the  capacity  of  the  cavity  of  the  unimpregnated 
uterus  is  from  \  to  \  of  a  cubic  inch,  so  that  there  is 
plenty  of  room  for  the  ovum  to  move  about,  even  in 
the  virgin  uterus,  and  a  cavity  of  double  or  triple 
the  normal  size  cannot  make  much  difference  in 
this  respect.  A  man  can  be  drowned  just  as  easily 
in  eight  feet  of  water  as  in  eight  hundred.  Still, 
from  the  general  fact  that  in  multiparous  women  the 
uterus  is  often  large,  it  is  probable  that  enlarge- 
ment of  the  uterine  cavity  is  a  frequent  antecedent 
of  placenta  proa  via.  Placenta  prsevia  is  rare  with 
twins :  because  the  condition  of  the  endometrium, 
which  prevents  the  ovum  from  getting  embedded  in 

U— 36 


.306  •      Difficult  Labour. 

the  proper  place,  will,  if  two  ova  enter  the  uterine 
cavity,  probably  lead  to  the  escape  of  one  of  them  alto- 
gether. Smoothness  of  the  endometrium,  so  that  the 
ovum  does  not  get  embedded,  and  loss  of  the  ciliated 
epithelium,  so  that  there  is  no  longer  any  upward 
current  preventing  the  ovum  from  travelling  down- 
wards, have  been  assigned  as  reasons ;  and  with  much 
plausibility,  as  these  changes  might  be  produced  by 
endometritis.  Cases  have  been  published  in  which 
pregnancy  with  placenta  previa  has  followed  measles, 
a  disease  which,  when  it  occurs  in  an  adult  woman,  is 
often  attended  with  endometritis.  The  probability 
is  that  degeneration  or  inflammation  of  the  endome- 
trium is  the  great  cause  of  placenta  praevia ;  but  at 
present  we  know  nothing  whatever  about  the  morbid 
anatomy,  or  the  symptoms,  of  the  disease  of  the  en- 
dometrium which  produces  placenta  praavia ;  and 
therefore  we  can  neither  predict  nor  prevent  this 
complication  of  labour. 

Placenta  praevia  may  occur  more  than  once  in 
the  same  patient;  but  there  is  no  marked  tendency 
for  it  to  do  so,  and  probably  much  can  be  done  to 
prevent  it  by  treatment  during  the  lying-in  directed 
towards  ensuring  complete  involution. 

Characters  of  the  praevia  placenta. — It  is 
seldom  exactly  central.  It  is  usually  larger  and 
thinner  than  the  normal  placenta.  The  reason  is  that 
the  uterine  decidua  gets  thinner  as  it  nears  the  internal 
os.  There  is,  therefore,  less  tissue  in  which  the  chori- 
onic villi  can  find  nutriment ;  and  to  compensate  for 
this,  the  placenta  spreads  over  a  larger  area.  From 
the  imperfection  of  the  decidua  it  also  results  that  the 
placental  villi  are  often  in  groups  or  islands;  there  are 
sometimes  gaps  from  which  villi  are  absent,  and  thus 
the  placenta  may  acquire  an  unusual  shape,  being 
lobed, or  horse-shoe-shaped;  and  succenturiate  placentae 
are  common.  The  placenta  makes  up  in  breadth  what 
it  lacks  in  thickness  and  closeness  of  texture. 

The  part  of  the  placenta  which  lay  over  the  os 
is   often   after  delivery   darker  than   the    rest,  fiom 


Clinical  History  of  Placenta  Prmvia.     307 

conditions  like  those  that  produce  the  caput  succe- 
daneum  on  the  foetal  head.  The  part  near  the  os  is 
often  the  thinnest,  because  here  the  decidua  is  thinnest. 
White  fibrous  lumps,  the  remains  of  old  clots,  are 
very  common  in  the  prsevia  placenta.  Adhesion  of 
the  prsevia  placenta  is  commoner  than  adhesion  of 
normally  situated  placenta.  Thickening  of  the  decidua 
is  common  with  placenta  prsevia ;  and  is  an  indication 
of  the  part  that  change  in  the  endometrium  plays  in 
its  causation. 

The  effect  of  placenta  praevia  on  the  uterus. 

— In  that  part  of  the  uterine  wall  where  the  placenta  is 
attached  the  vessels  are  enormously  developed.  When 
this  vascularity  affects  the  lower  segment  of  the 
uterus,  it  makes  the  dilatation  slow  and  difficult,  and 
therefore  prolongs  the  first  stage  of  labour.  It  also 
disturbs  the  polarity  of  the  uterus,  and  thus  makes 
the  pains  irregular  and  weak.  From  the  bruising, 
and  possibly  tearing,  of  the  veins  in  the  lower  segment 
which  may  take  place  in  delivery,  there  is  a  special 
liability  to  uterine  phlebitis  after  labour,  and  to 
pysemia  as  its  result ;  and  therefore  there  is  special 
need  for  care  in  regard  to  antisepsis. 

Clinical  history. — It  is  thought  that  in  placenta 
prsevia  there  is  a  tendency  to  early  abortion,  and  it  is 
said  that  such  abortions  occur  without  apparent  cause, 
that  the  pain  and  haemorrhage  are  very  slight,  and 
that  the  ovum  is  often  expelled  unbroken,  owing  to 
the  ease  with  which  the  process  takes  place.  This  ia 
only  theory,  because  abortions  in  which  it  can  be 
ascertained  that  the  placenta  was  being  formed  over 
the  lower  pole  of  the  ovum  are  very  rare.  But  it  is 
probably  true  ;  though  the  condition  can  hardly  be 
called  placenta  prsevia  until  the  placenta  has  been 
formed.  Most  subjects  of  placenta  praevia  go  through 
the  first  half  of  pregnancy  without  abnormal  symptoms. 

Haemorrhage. — The  great  symptom  is  haemor- 
rhage, from  the  separation  of  the  placenta.  This 
usually  begins  about  the  seventh  or  eighth  month ; 
sometimes  earlier,  as  might  be  expected  if  abortion 


308  Difficult  Labour. 

from  this  cause  be  common.  Bleeding  may  come  on 
without  pains  or  appreciable  dilatation  of  the  cervix, 
and  be  so  great  as  either  to  cause  death,  or  by  its 
repetition  to  keep  the  patient  very  anaemic.  It  is  the 
liability  of  the  patient  to  haemorrhage  that  makes 
placenta  praevia  so  dangerous. 

The  more  central  the  placenta,  the  earlier  the 
haemorrhage.  Statistics  show  that  the  usual  time  for 
the  first  haemorrhage  in  central  placenta  praevia  is 
from  the  twenty-eighth  to  the  thirty-sixth  week ; 
in  lateral,  after  the  thirty-second  week. 

When  bleeding  has  once  taken  place  it  recurs 
irregularly  until  delivery.  As  a  rule,  the  earlier  the 
haemorrhage  the  slighter  it  is,  because  the  vessels 
laid  open  are  smaller.  The  bleeding  is  stopped  by 
thrombosis  of  the  vessels ;  and  the  vessels  so  plugged 
do  not  bleed  again ;  hence,  when  the  next  attack  of 
haemorrhage  comes,  there  are  fewer  vessels  to  be  laid 
open.  If  the  haemorrhage  is  postponed  till  the 
beginning  of  labour  at  term,  it  is  usually  great,  because 
then,  large  vessels  not  previously  thrombosed  are  laid 
open  as  the  placenta  becomes  separated. 

The  haemorrhage  as  a  rule  comes  on  suddenly, 
without  warning.  Sometimes  there  seems  to  be  an 
exciting  cause,  such  as  some  effort,  or  shock,  or  local 
violence  ;  but  this  is  exceptional.  It  generally  ceases 
spontaneously. 

Delivery  may  take  place  with  slight  haemorrhage, 
and  cases  have  even  been  recorded  of  delivery  without 
haemorrhage.  The  conditions  which  cause  bleeding 
during  delivery  to  be  slight  are  :  marginal  insertion  of 
placenta,  adhesion  of  the  placenta,  death  of  the  child 
before  labour,  and  copious  haemorrhage  during  preg- 
nancy leading  to  extensive  thrombosis  of  yessels. 
Although  the  death  of  the  child  stops  the  circulation 
through  the  foetal  part  of  the  placenta,  and  may  be 
supposed  to  make  the  circulation  through  the  maternal 
part  less  active,  yet  there  is  abundant  evidence  that 
the  death  of  the  child  is  no  security  against  dangerous 
haemorrhage. 


HEMORRHAGE    IN  PLACENTA    PrMVIA.        309 

Modes  of  production  of  the  haemorrhage- 
There  are  two  ways  in  which  bleeding  is  caused  in 
placenta  prsevia  ;  (1)  physiological,  and  (2)  accidental. 

(1)  Usually  a  few  days  before  the  patient  feels  labour 
pains,  sometimes  as  much  as  two  months  before, 
the  circular  fibres  surrounding  the  internal  os  are 
inhibited,  and  the  longitudinal  fibres  of  the  body 
of  the  uterus  pull  up  its  lower  segment,  thereby 
opening  the  internal  os,  and  making  the  cavity 
of  the  cervix  a  part  of  the  uterine  cavity.  When 
this  opening  up  of  the  internal  os  has  taken  place 
the  lower  pole  of  the  bag  of  membranes  sinks 
down,  and  lies  on  the  external  os,  instead  of  on  the 
internal  os  as  it  did  before.  For  this  sinking  to  take 
place  there  must  be  a  separation  of  the  decidua  over  a 
slight  area.  Now,  if  the  placenta  forms  the  lower  pole 
of  the  bag,  some  of  the  placenta  either  must  be  separated 
or  must  stretch.  The  separation  lays  open  uterine 
vessels  and  causes  the  bleeding.  Separation  of  the 
placenta    in    this    way    is    a    physiological   process 

(2)  When  the  placenta  is  low  down  the  veins  which 
return  blood  from  it  are  under  greater  pressure  than 
when  the  placenta  is  high  up.  Hence  rupture  of 
vessels  is  more  likely  to  take  place.  A  strain,  a  shock, 
contact,  or  increase  in  the  blood  pressure,  may 
provoke  haemorrhage.  Such  bleeding  may  come 
(a)  from  the  uterus,  by  detachment  of  placental  villi, 
or  (b)  from  the  placenta,  by  vessels  in  the  placenta 
giving  way.  These  vessels  are  very  thin-walled,  and 
in  the  thin  spread-out  prsevia  placenta  they  are  not 
mutually  supported,  as  in  the  normal  placenta  (The 
frequency  of  clots  and  white  fibrous  lumps,  the 
remains  of  clots,  in  the  pi-sevia  placenta  has  already 
been  mentioned.)  Bleeding  taking  place  before  the 
internal  os  has  opened  up  is  accidental. 

Frequency  of  premature  labour. — In  placenta 

prsevia  premature  labour  is  the  rule.  Not  more  than 
a  third  of  the  cases  go  to  term.  Labour  usually 
follows  haemorrhage. 

The  pains. — As  a  rule,  with  placenta  prsevia  the 


3io  Difficult  Labour. 

pains  are  weak.  This  is  because  (1)  the  implantation 
of  the  placenta  on  the  lower  uterine  segment  disturbs 
the  polarity  of  the  uterus ;  (2)  the  stimulus  of  the 
impact  of  the  presenting  part  against  the  cervix  is 
lacking,  (a)  because  the  placenta  is  interposed,  (b) 
because  transverse  presentations  are  common;  (3) 
the  patient  during  the  labour,  if  not  before,  is  often 
exhausted  by  haemorrhage.  Labour  goes  on  badly 
because,  further,  (4)  as  these  labours  are  generally 
premature,  the  os  internum  is  not  dilated  as  it  is 
prior  to  labour  at  term,  but  the  whole  cervical  canal 
has  to  be  opened  up  from  above  downwards ;  and  (5) 
the  lower  pole  of  the  ovum,  formed  by  the  placenta,  does 
not  advance  into  the  os  and  dilate  it  so  quickly  as  it 
should  do.  With  weakness  of  pains  there  is  often  found 
irregularity  of  pains.  It  is  not  uncommon,  when  the 
resistance  of  the  cervix  has  been  overcome,  for  the  pains 
to  grow  strong  and  rapidly  end  the  labour.  On  the 
other  hand,  often  when  labour  has  begun  with  fairly 
good  pains,  after  a  time,  when  the  patient  has  become 
exhausted  from  haemorrhage  they  get  weaker  and  cease 
Malpresentations. — In  placenta  prsevia  the  pro- 
portion of  transverse  presentations  to  those  in  which 
the  long  axis  of  the  child  occupies  that  of  the  uterus 
is  about  one  to  three — that  is,  transverse  positions 
are  about  fifty  times  as  frequent  as  in  labours 
generally.  The  reasons  for  this  are  (1)  that  so 
many  of  the  labours  are  premature ;  (2)  the  placenta 
fills  up  the  lower  uterine  segment,  and  makes  it 
less  easy  for  the  end  of  the  foetal  ovoid  to  engage 
in  the  pelvis ;  (3)  the  contractile  power  of  the 
uterus  is  impaired.  Another  explanation  is  also 
given — viz.  that  lateral  placenta  previa  takes  up 
room  on  one  side,  and  pushes  the  end  of  the  foetal 
ovoid  over  to  the  other  side.  If  this  were  the  chief 
reason,  transverse  presentations  ought  to  be  more 
frequent  with  lateral  than  with  central  placenta 
praevia ;  but  the  reverse  is  the  case.  The  praevia 
placenta  is  so  thin  that  it  does  not  much  alter  tlie 
shape  of  the  uterine  cavity. 


Hmmorrhage  in  Placenta  Pr/evia.      311 
Production  and  arrest  of  haemorrhage.— I 

have  said  that  the  haemorrhage  is  produced  by  the 
separation  of  the  placenta  in  the  onward  movement 
of  the  bag  of  membranes.  It  is  not  produced  solely 
by  the  dilatation,  because  the  placenta  can  stretch  a 
little,  and  so  follow  the  uterus  in  its  expansion.  But 
with  the  dilatation  there  goes  onward  movement  of  the 
bag  of  membranes.  This  first  puts  the  villi  round 
the  os  internum  on  the  stretch,  and  then  breaks  them 
away  from  the  uterus.  The  resistance  to  the  break- 
ing away  of  the  placenta  is  greatest  at  the  side  where 
the  placenta  is  largest  and  thickest.  Hence  it  will  be 
completely  detached  at  the  side  where  the  smallest 
part  of  the  placenta  is  situated,  before  the  detachment 
is  complete  at  the  other  side.  In  other  words,  the 
effect  of  the  pains  is  to  convert  central  placenta 
prsevia  into  partial.  When  this  has  been  done,  if  the 
head  or  breech  of  the  child  comes  into  the  os  uteri, 
and  the  pains  are  strong,  the  advancing  part  of  the 
child  presses  on  the  bleeding  vessels  and  stops  the 
haemorrhage.  At  the  same  time  the  separation  of 
the  placenta  allows  the  uterus  to  retract,  and  by 
its  retraction  the  muscular  fibres  compress  the  vessels. 
In  these  two  ways  bleeding  is  stopped,  and  when  it 
is  stopped  the  blood  in  the  vessels  clots,  and  thus  the 
arrest  of  haemorrhage  becomes  permanent. 

Birth    of   placenta    before   the   child. — A 

central  placenta  praevia  is  sometimes  not  converted 
into  a  lateral  one.  If  the  pains  are  strong,  the 
placenta  becomes  tensely  stretched  before  the  ad- 
vancing part  of  the  child,  and  may  be  detached  all 
round,  and  driven  down  before  the  child.  Such 
cases,  as  Sir  J.  Simpson  showed,  usually  do  well. 
This  is  because  strong  pains  are  required  for  it,  and 
cases  with  strong  pains  generally  do  well.  Delivery 
of  the  placenta  before  the  child  may  take  place 
either  prematurely  or  at  full  term,  and  with  any 
position  of  the  child.  The  child  usually,  but  not 
invariably,  follows  quickly  after  the  placenta.  This 
mode  of  delivery  is  unfavourable  to  the  child,  because 


312  Difficult  Labour. 

the  separation  of  the  placenta  deprives  it  of  oxygen. 
Three-fourths  of  the  children  so  delivered  are  still-born. 

Death  during  or  soon  after  delivery.— A 

patient  with  placenta  previa  is  not  out  of  danger  as 
soon  as  she  is  delivered.  When  the  patient  is  very 
prostrate,  the  effect  of  the  sudden  emptying  of  the 
uterus,  in  lowering  the  pressure  within  the  abdomen, 
may  be  to  withdraw  blood  from  the  brain  and  heart 
so  as  to  cause  fatal  syncope.  The  most  common 
mode  of  death  with  placenta  praavia  is  by  post- 
partum haemorrhage.  Bleeding,  not  more  than  that 
usual  in  the  third  stage  of  labour,  may  be  enough  to 
kill  a  patient  much  weakened  by  loss  of  blood  before 
delivery.  The  danger  is  often  increased  by  a  doctor  who 
acts  on  the  pernicious  maxim — "deliver  as  quickly 
as  possible."  One  who  has  this  in  his  mind  drags  out  the 
child  when  the  uterus  is  not  acting,  and  then  post- 
partum haemorrhage  kills  the  patient.  Further,  a 
patient  in  whom  the  haemorrhage  of  the  third  stage 
has  been  stopped  may  yet,  if  she  has  been  greatly 
exhausted,  pass  gradually  into  collapse  and  die,  with- 
out further  loss  of  blood. 

Adherent  placenta. — More  or  less  placental 
adhesion  (i.e.  placenta  needing  to  be  stripped  off  by 
the  fingers)  is  found  in  about  one-fifth  of  all  cases. 

Dangers  in  the  lying-in  period. — It  has  been 

pointed  out  that  with  placenta  praavia  the  lower  uterine 
segment  is  more  vascular  and  dilates  badly.  Hence 
greater  injury  than  usual  is  inevitable  during  delivery; 
and  injury  means  greater  liability  to  inflammation. 
The  patients  are  exhausted,  and  therefore  less  able 
to  resist  morbid  influences.  In  pre-antiseptic  times 
"puerperal  fever"  in  its  different  forms  occurred 
oftener  after  placenta  praavia  than  after  ordinary 
labours.  There  was  plenty  of  dead  tissue,  such  as 
fragments  of  placenta,  etc.,  which  were  liable  to 
decompose.  Peritonitis  was  the  most  common  form, 
then  uterine  phlebitis,  pyaemia,  then  endometritis. 

Entrance  of  air  into  vein.* — In  separating  the 

*  See  Kr«uner,  Zcit.  fur  Get,  und  Gyn.,  Bd.  xiv. 


Prognosis  in  Placenta  Prmvia.        313 

placenta  air  has  been  known  to  enter  a  vein  and  kill 
the  patient. 

Effects  of  loss  Of  blood. — The  anaemic  condition 
of  a  patient  after  delivery  with  placenta  praevia 
renders  her  especially  liable  to  phlegmasia  dolens, 
pulmonary  embolism,  and  insanity. 

Prognosis. — In  placenta  praevia  the  life  of  the 
mother  and  that  of  the  child  are  antagonistic.  Treat- 
ment to  save  the  child  imperils  the  mother,  and  what 
is  best  for  the  mother  often  leads  to  the  child's  death. 
Miiller,  writing  in  pre-antiseptic  times,  put  the 
maternal  mortality  during  and  after  labour  at  nearly 
40  per  cent.,  and  that  of  the  children  at  64  per  cent. 
But  since  the  introduction  of  antiseptics,  and  the 
treatment  taught  by  Dr.  Braxton  Hicks,  the  mortality 
of  the  mothers  in  cases  properly  treated  is  not  more 
than  about  5  per  cent.,  whilst  that  of  the  children 
has  become  at  least  90  per  cent. 

Circumstances  on  which  prognosis  depends. 
— (1)  The  earlier  the  labour  comes  on  the  less  is  the 
danger,  because  the  earlier  the  labour  the  less  the 
haemorrhage.  (2)  Central  placenta  praevia  is  more 
dangerous  than  lateral,  and  lateral  than  marginal : 
for  the  more  nearly  central  the  placenta,  the  earlier 
and  the  greater  is  the  haemorrhage,  the  greater  the 
liability  to  mal presentations,  the  less  efficient  the 
uterine  contractions.  (3)  The  stronger  the  pains, 
the  more  quickly  is  the  placenta  separated,  the  more 
rapid  is  the  labour,  the  sooner  is  haemorrhage  stopped, 
and  the  better  are  uterine  retraction  and  contraction 
after  delivery.  From  weak  pains  the  reverse  effects 
follow.  (4)  Malpresentations  make  the  prognosis 
graver,  because  they  delay  delivery,  and  call  for  inter- 
ference. (5)  If  the  cervix  is  rigid  the  prognosis  is 
worse;  if  it  is  soft  and  dilatable  the  reverse.  (6)  Any 
complication  makes  the  prognosis  worse,  just  as  it 
would  that  of  any  other  labour.  The  points  upon 
which  the  prognosis  for  the  child  depends  will  be 
spoken  of  in  connection  with  treatment. 

Diagnosis. — It    used    to   be    said   that  placenta 


314  Difficult  Labour. 

praevia  could  be  distinguished  from  accidental  haemor- 
rhage by  the  relation  of  the  bleeding  to  the  pains ; 
that  in  placenta  praevia  the  blood  flowed  during  the 
pains,  in  accidental  haemorrhage  between  the  pains. 
This  is  quite  true  as  to  the  escape  of  blood  from  the 
vessels :  for  in  placenta  praevia  the  pains,  by  forcing 
clown  the  ovum,  tear  across  utero-placental  vessels, 
while  in  accidental  haemorrhage  uterine  contractions 
compress  the  vessels,  and  so  tend  to  stop  haemorrhage. 
But  the  distinction  is  of  no  clinical  use :  for  in  placenta 
praevia  blood  may  flow  into  the  vagina  during  the 
pains,  and  escape  outside  between  them ;  and  in 
accidental  haemorrhage,  blood  poured  out  while  the 
uterus  was  relaxed,  may  be  forced  outside  by  the 
bearing-down  effort  accompanying  a  pain. 

Abdominal  palpation.— The  diagnosis  of  placenta 
praevia  has  been  made  by  abdominal  palpation  :  the 
hands,  when  pressed  into  the  pelvic  brim,  have  detected 
below  the  presenting  part  of  the  child  a  thick  mass.* 
As  this  has  been  done,  it  may  be  done  again.  But  in 
most  cases  it  cannot  be  done,  because  the  placenta  is 
thin  and  spread  out,  and  does  not  form  a  lump  that 
can  be  felt. 

Vaginal    examination. — In    most   cases   the 

diagnosis  of  placenta  praevia  cannot  be  made  till  the 
cervical  canal  will  admit  the  finger.  Till  then  the 
condition  can  only  be  suspected.  Physical  characters 
of  the  cervix  and  lower  uterine  segment  have  been 
described  from  which  placenta  praevia  may  be  sus- 
pected, but  none  definite  enough  to  be  useful.  When 
the  cervix  admits  the  finger,  either  the  smooth  mem- 
branes or  the  spongy  placenta  is  felt,  and  this  settles 
the  diagnosis.  In  lateral  placenta  praevia  the  edge  of 
the  placenta  will  be  felt  on  one  side  only,  and  in 
marginal  it  will  not  be  felt  until  the  finger  has  been 
swept  around  the  lower  zone  of  the  uterus. 

Treatment. — I   shall   first   review  the  different 
means  for  the  treatment  of  placenta  praevia,  and  then 
deduce  rules  for  guidance  in  practice.     The  prognosis 
*  See  Spencer,  Obst.  Trans.,  vol.  xxxi. 


Treatment  of  Placenta   Pr.evia.      315 

in  placenta  prsevia  is  better  the  earlier  labour  comes  on. 
This  points  out  the  tirst  principle  in  treatment,  viz. 
bring  on  labour  as  soon  as  diagnosis  has  been  made. 

A.  Rupture  of  membranes. — This  is  done  that 

by  lessening  the  bulk  of  the  uterine  contents  it  may 
provoke  uterine  contraction,  and  enable  the  uterus  to 
embrace  the  child  more  closely  and  drive  the  present- 
ing part  down  upon  the  bleeding  vessels.  This  is 
likely  to  succeed  if — (1)  there  are  good  pains ;  (2)  the 
presenting  part  is  the  head  or  breech ;  (3)  the  os  uteri 
is  dilated  enough  for  the  presenting  part  to  enter  it. 

On  the  other  hand,  (1)  if  there  be  not  good  uterine 
action  rupture  of  membranes  may  not  provoke  it,  and 
in  that  case  the  benefit  of  the  bag  of  waters  will  be 
lost  and  nothing  gained ;  (2)  if  the  presenting  part 
be  not  the  head  or  breech  it  will  not  press  effectively 
on  the  bleeding  part,  and  rupture  of  the  membranes 
will  only  make  turning  difficult;  (3)  if  the  os  uteri 
be  small  or  rigid,  rupture  of  the  membranes  deprives 
us  of  the  natural  and  best  dilating  agent. 

B.  Dilatation  Of  the  Cervix. — This  has  formed  a 
part  of  almost  every  plan  of  treatment  that  has  been 
proposed.  It  is  usually  necessary,  because  dilatation 
of  the  cervix  must  precede  delivery,  and  in  placenta 
praavia  the  lower  uterine  segment  is  vascular  and 
dilates  badly,  and  the  pains  which  should  dilate  it  are 
generally  deiicient  or  absent. 

Different  modes  of  dilatation  have  been  advised  — 
cutting  with  a  bistoury;  tearing,  as  in  the  "accouche- 
ment force "  /  stretching  open  with  the  fingers ; 
gradual  dilatation  by  tents  or  water-bags.  Cutting 
and  tearing  are  bad  :  they  make  unnecessary  wounds, 
and  add  to  the  danger  both  of  haemorrhage  at  the 
time  and  of  puerperal  disease  afterwards.  Stretching 
open  with  the  fingers,  if  done  slowly  and  gently,  is 
better.  But  it  is  difficult  so  to  regulate  the  force 
employed  as  to  dilate  simpty,  without  tearing.  The 
best  way  of  dilating  is,  when  the  os  will  not  easily 
admit  the  finger,  by  Hegar's  dilators ;  when  the 
os    will    easily    admit    the    finger,    by    a    water-bag. 


3i 6  Difficult  Labour. 

The  dilatation  by  these  agents  is  slow,  gentle,  and 
uniform.  The  bag  at  once  dilates  the  cervix  and 
plugs  it.  The  best  form  of  water-bag  is  that  of 
Champetier  de  Ribes  (p.  436).  This  has  the  shape 
of  an  inverted  cone,  the  apex  of  the  cone  being 
in  the  os  internum.  The  base  is  of  such  a  size  that 
when  it  has  passed  through  the  os  delivery  can 
at  once  be  effected.  It  is  made  of  inelastic  water- 
proof silk  which  will  not  stretch.  The  diluting 
pressure  of  this  instrument  is  gentle  and  uniform  ; 
it  is  an  almost  exact  imitation  of  the  natural  1i.il; 
of  the  membranes.  Barnes's  bags  may  be  used, 
but  they  are  inferior,  for  they  involve  repeated 
manipulations,  and  do  not  so  well  dilate  the  cervix. 
You  may  be  called  to  treat  a  case  when  you  have 
not  with  you  a  water-bag,  and  in  such  ch'cum  stances 
digital  stretching  of  the  cervix  may  be  preferable 
to  the  delay  involved  in  sending  for  the  dilating 
instruments.  With  Hegar's  dilators,  the  cervix 
can  be  rapidly  dilated  up  to  a  size  which  will 
admit  Champetier's  bag.  It  is  better  not  to  hasten 
delivery  by  pulling  on  the  bag,  but  to  let  the  uterus 
expel  the  bag  into  the  vagina ;  for  if  you  pull  out  the 
bag  the  temptation  is  great  to  pull  out  the  child,  and 
if  this  is  done  when  the  uterus  is  not  contracting, 
dangerous  post-partum  haemorrhage  will  probably 
follow. 

0.  The  "  aCCOUVChement  force,"  which  is  some- 
times recommended,  means  the  rapid  forcing  open 
(that  is,  tearing  open)  of  the  os  with  the  hand,  separa- 
tion of  the  placenta,  turning  and  rapid  dragging  away 
of  the  child,  followed  by  the  removal  of  the  placenta. 
This  is  the  most  dangerous  of  all  modes  of  treatment. 
Rigby  cautioned  against  it.  Miiller  rightly  terms  it 
a  "  murderous  "  practice.  Statistics  show  that  about 
half  the  cases  so  treated  die  ;  the  usual  cause  of  death 
being  post-partum  haemorrhage. 

D.  Turning",  first  practised  by  Portal  (1685),  has 
long  been  recognised  as  good  treatment.  The  advan- 
tage of  turning  is  that  the  thigh  is  brought  into  the 


Treatment  of  Placenta  Previa.       317 

cervix  uteri,  and  the  breech  presses  on  the  bleeding 
part.  The  soft  thigh  dilates  the  cervix  gently,  and 
stimulates  uterine  action.  The  diminution  in  bulk  of 
the  uterine  contents,  from  the  withdrawal  of  one  leg 
and  the  liquor  amnii,  helps  the  retraction  of  the  uterus, 
by  which  haemorrhage  is  stopped.  Turning  was  not 
in  former  times  very  successful,  because  it  was  thought 
necessary  to  put  the  hand  in  the  uterus  to  turn  ;  and 
this  belief  led  to  either  the  hand  being  forced  through 
the  undilated  cervix  {accouchement  force)  or  turning 
being  postponed  until  the  os  would  admit  the  hand, 
a.  delay  which  often  led  to  great  haemorrhage ;  and  it 
was  the  frequency  of  haemorrhage  while  the  os  was 
dilating  that  drove  some  to  prefer  the  accouchement 
force.  But  in  recent  times  Dr.  Braxton  Hicks  has 
taught  the  bipolar  method  of  turning,  by  which  you 
can  turn  as  soon  as  the  os  uteri  will  admit  two  fingers. 
This  method,  combined  with  antiseptics,  has  brought 
the  mortality  down  to  about  5  per  cent.  The 
accouchement  force  gives  the  best  result  for  the  child. 
Early  turning  followed  by  slow  extraction  sacrifices 
the  child,  but  saves  the  mother.  The  treatment  best 
for  the  majority  of  cases  of  placenta  praevia  may  be 
epitomised  as  follows  :  Early  turning,  slow  extraction, 
antiseptics. 

E.  Simpson's  method :  Delivery  of  placenta 

first. — Sir  J.  Simpson  recommended  this  method,  on 
the  ground  that  statistics  of  cases  in  which  the  placenta 
was  first  delivered  showed  better  results  than  those  in 
which  this  did  not  happen.  The  average  mortality  of 
placenta  praevia  at  that  time  was  about  one  in  four ; 
that  of  cases  in  which  the  placenta  came  first  about 
one  in  fourteen.  But  he  compiled  these  statistics 
mainly  from  cases  in  which  the  placenta  was  naturally 
delivered  first.  Now,  these  are  all  cases  in  which 
there  were  strong  pains,  and  this  is  why  the  statistics 
are  favourable.  The  practice  of  artificially  delivering 
the  placenta  first  has  not  been  followed  by  good 
results.  R.  Barnes  says  it  is  impossible,  because 
the  finger  cannot  reach  farther  than  over  a  circle  of 


318  Difficult  Labour. 

two  inches'  radius  round  the  os.  This  is  true  in  the 
beginning  of  labour,  but  when  dilatation  has  gone  on 
to  some  extent  the  finger  can  reach  proportionately 
farther. 

F.  Separation  of  the  placenta. — This  practice 

was  first  introduced  by  Cohen,  who  advised  separating 
the  placenta  on  the  side  at  which  the  smaller  half  was 
attached,  thus  converting  a  central  into  a  lateral 
placenta  praevia.  R.  Barnes  carried  it  further,  and 
advocated  separation  of  the  placenta  all  round,  claim- 
ing for  this  that  (1)  a  hindrance  to  dilatation  is 
removed,  (2)  that  often  the  bleeding  stops.  The 
statement  that  "often  the  bleeding  stops"  gives  an 
impression  of  security  against  haemorrhage  that  ex- 
perience does  not  bear  out.  It  is  &  most  dangerous 
thing  to  leave  a  patient  after  the  placenta  has  been 
separated,  with  the  idea  that  haemorrhage  will  not 
return.  The  separation  of  the  placenta  allows  the 
lower  pole  of  the  ovum  to  advance  into  the  os  uteri, 
and  thus  helps  dilatation  and  stimulates  uterine 
contraction,  and  for  this  reason  it  is  a  good  practice. 
But  if  pains  with  good  uterine  retraction  do  not  come 
on,  the  danger  of  haemorrhage  is  increased  by  separa- 
tion of  the  placenta,  in  proportion  to  the  area  over 
which  utero-placental  vessels  are  laid  open.  In  short, 
separation  of  the  placenta  only  stops  haemorrhage  in 
so  far  as  it  accelerates  delivery. 

G.  Perforation  of  the  placenta. — This,  followed 

by  podalic  version,  is  one  of  the  oldest  methods  of 
delivery.  As  a  rule  it  is  not  desirable,  for  cases  of 
placenta  praevia  so  central  that  the  edge  can  nowhere 
be  reached  are  rare ;  and  if  the  edge  can  be  reached, 
it  is  much  easier  to  rupture  the  membranes  close  to 
the  placenta  than  to  perforate  the  placenta.  But  if 
the  placenta  be  so  central  that  the  edge  cannot  be  got 
at,  then  the  best  thing  is  to  push  the  fingers  through 
the  placenta.  If  the  placenta  be  thick,  it  is  not  easy  to 
perforate  it ;  but  it  is  generally  thin.  Perforation  of 
the  placenta  means  tearing  across  of  placental  vessels, 
and  therefore  lessening  of  the  child's  chance  of  life. 


Treatment  of  Placenta  Previa.       319 

H.  The  forceps  is  only  seldom  suitable  in 
placenta  previa.  In  partial  placenta  prsevia,  with  the 
head  presenting,  the  membranes  ruptured,  the  os 
uteri  dilated  to  four-fifths  of  its  size,  delivery  with 
forceps  will  be  the  best  practice.  Care  should  be 
taken  not  to  pass  a  blade  between  the  placenta  and 
the  uterine  wall. 

I.  Plugging  the  vagina. — About  this  there 
has  been  great  difference  of  opinion.  For  the  last 
hundred  years  some  obstetric  authorities  have  recom- 
mended it  and  others  disapproved  it.  Most  various 
materials  have  been  advised — wool,  lint,  sponge, 
charpie,  tow,  linen,  silk,  etc.  ;  and  some  have  soaked 
these  things  in  oil,  albumen,  vinegar,  alum,  iron,  or 
tannin  solution,  etc.  To  expect  to  stop  bleeding  from 
the  uterus  by  applying  a  drug  to  the  vagina  is  absurd. 
The  effect  of  the  plug  is  mechanical.  It  is  supposed 
to  act  in  three  ways  :  (1)  By  stopping  up  the  vagina 
the  blood  is  prevented  from  getting  out ;  (2)  by  tightly 
packing  the  vagina  the  bleeding  lower  segment  of  the 
uterus  is  compressed  between  the  plug  and  the 
presenting  part  of  the  child ;  (3)  the  pressure  of  the 
plug  stimulates  the  uterus  to  contract.  Except  the 
last,  these  effects  of  the  plug  are  so  temporary  as  to 
be  valueless.  To  stuff  the  vagina  really  tight  is  a 
difficult  thing  to  do,  and  very  painful  to  the  patient. 
The  vagina  is  capable  of  great  distension.  When  it 
is  plugged  the  tension  of  the  vaginal  walls  presses  the 
material  of  the  plug  closer  together,  so  that  it  becomes 
smaller ;  and  the  vagina  soon  stretches,  so  that  in  a 
little  while  the  plug,  which  at  first  seemed  firm, 
becomes  a  slippery  ball,  past  which  blood  easily  flows, 
and  which  fits  too  loosely  to  compress  the  cervix. 
When  the  os  is  too  small  to  allow  delivery,  plug- 
ging is  invaluable ;  but  you  should  plug  the  cervix, 
not  the  vagina.  The  thing  to  plug  it  with  is  a 
laminaria  tent  or  tents. 

J.  Ergot. — Uterine  retraction  and  contraction  are 
a  prime  necessity  in  placenta  prsevia,  and  therefore 
ergot  should  always  be  given  unless  contra-indicated. 


320  Difficult  Labour. 

As  most  placenta  praevia  labours  are  premature,  there 
is  seldom  danger  in  giving  ergot.  The  drawback  to 
its  usefulness  is  that  in  so  many  cases  the  contractile 
power  of  the  uterus  is  exhausted  and  ergot  will  not 
act.     Still,  it  does  no  harm  to  give  it. 

These  being  the  methods  at  our  disposal,  how  shall 
they  be  applied  in  practice?  Consider  the  different 
stages  of  the  case. 

As  to  "temporising'."  —  Haemorrhage  during 
pregnancy,  coming  from  the  body  of  the  uterus,  when 
the  os  uteri  will  not  admit  the  finger,  and  not  copious 
enough  to  affect  the  patient's  health  seriously,  should 
be  treated  in  the  way  that  I  have  recommended  (page 
298)  for  slight  accidental  haemorrhage.  If  the  bleeding 
is  so  great  as  clearly  to  weaken  the  patient,  whatever 
the  site  of  the  placenta,  the  pregnancy  should  l>e 
ended. 

As  soon  as  ever  placenta  praevia  is  found  out,  be 
the  bleeding  great  or  little,  labour  ought  to  be  brought 
on.  The  patient  is  not  safe  from  haemorrhage  until 
she  is  delivered.  Some  advise  to  temporise  until  the 
child  is  viable.  But  as  the  mortality  among  the 
children  in  cases  of  placenta  praevia  treated  with  due 
regard  to  the  mother's  safety  is  90  per  cent.,  the 
temporising  practice  exposes  the  mother  to  risk  for  a 
very  small  chance  of  saving  a  premature  child,  difficult 
to  rear.  Temporising  consists  in  letting  the  case  take 
its  course,  and  not  treating  the  haemorrhage,  for  there 
is  no  treatment  except  delivery  which  will  stop 
haemorrhage  in  placenta  praevia. 

Before  diagnosis. — Suppose  that  the  patient  is 
six  months  pregnant.  Her  pallor  and  the  smallness  of 
her  pulse  show  that  the  haemorrhage  has  been  severe. 
The  cervix  uteri  will  not  admit  a  finger,  and  you 
cannot  tell  whether  the  haemorrhage  is  accidental  or 
due  to  placenta  praevia.  But  as  the  patient  cannot 
stand  another  such  loss,  pass  a  sound  into  the  uterus, 
rupture  the  membranes  and  let  off  the  liquor  amnii,  and 
then  put  a  piece  of  laminaria  2  in.  long  into  the  cervix. 
Put  the  tent  in  sublimate  glycerine  1  in  1,000,  and  get 


TREATMENT  OF  PLACENTA    Pr&VIA.  32  I 

every  part  of  its  surface  covered  with  the  glycerine. 
Seize  the  auterior  lip  of  the  cervix  with  a  volsella 
and  pull  it  down.  Give  the  volsella  to  an  assistant 
to  hold.  Take  the  tent  in  a  speculum  forceps  held  in 
the  right  hand  ;  put  two  fingers  of  the  left  hand  up  to 
the  cervix  ;  pass  up  the  tent  in  the  hollow  between 
the  two  fingers  to  the  os  uteri ;  when  its  point  is  in 
the  os,  press  it  up  as  far  as  you  can  into  the  cervical 
canal  with  the  fingers  in  the  vagina.  This  will  at 
once  plug  (thus  to  some  extent  restraining  bleeding) 
and  dilate  the  cervix.  A  solid  piece  of  laminaria  is 
letter  than  a  tent  made  by  gluing  several  small  pieces 
together.     The  glue  may  be  unclean. 

Then  give  the  patient  ergot  in  doses  of  half  a  drachm 
every  four  hours.  Probably  labour  pains  will  come 
on,  and  first  the  tent  and  then  the  uterine  contents 
will  be  expelled.  At  this  early  period  of  pregnancy 
you  need  not  trouble  yourself  about  the  position  of 
the  child,  for  it  will  be  small  enough  to  come  through 
in  any  position  If,  after  the  tent  has  expanded  and 
the  cervical  canal  will  admit  the  finger,  expulsive  pains 
do  not  come  on,  perform  bipolar  version  with  one  finger 
in  the  cervix  until  you  get  a  foot  over  the  os  uteri, 
and  then  seize  this  foot  with  ovum  forceps  and  draw 
it  down  through  the  os.  If  you  find  this  manoeuvre 
difficult,  put  two  or  three  pieces  of  laminaria 
side  by  side  into  the  cervical  canal,  and  when  they 
have  further  expanded  the  cervix,  either  pains  will 
come  on  or  you  will  be  able  to  get  the  foot  down. 

After  Diagnosis. — Suppose  that  the  patient  is 
seven  or  eight  months  pregnant  and  there  has  been 
a  great  haemorrhage.  Usually  the  os  will  admit  the 
finger,  and  you  can  make  a  diagnosis.  If  the  placenta 
be  prsevia  you  will  feel  the  spongy  mass  of  the  pla- 
centa lying  over  the  os  if  it  be  central — at  the  side  if 
partial  or  marginal.  If  you  feel  the  placenta,  intro- 
duce the  finger  and  separate  the  placenta  all  round  as 
far  as  the  finger  will  reach.  This  will  make  the  ad- 
vance of  the  ovum  easier,  and  so  accelerate  delivery. 

Before  considering  what  is  to   be  done  when  the 
v— 36 


322  Difficult  Labour. 

cervix  will  only  admit  one  finger,  take  the  easier  case 
in  which  the  cervix  will  admit  two  fingers. 

Separate  placenta  and  turn. — if  the  os  uteri 

will  easily  admit  two  fingers,  there  is  no  doubt  as  to 
what  is  the  best  treatment.  Put  two  fingers  into  the 
os  and  sweep  them  round  between  the  placenta  and 
the  uterus,  so  as  to  separate  the  placenta  all  round  as 
far  as  the  fingers  can  reach.  The  fingers  will  reach 
about  an  inch  and  three  quarters  from  the  os  uteri. 
Supposing  that  the  os  uteri  is  an  inch  and  a  half  in 
diameter,  the  placenta  will,  when  this  has  been  done, 
have  been  separated  over  a  circle  about  five  inches  in 
diameter.  Now,  as  the  placenta  is  generally  more 
than  five  inches  in  diameter,  and  as  in  placenta  prsevia 
the  placenta  is  more  expanded  than  usual,  the  whole 
placenta  will  not  have  been  separated  when  this  has 
been  done.  If  its  centre  is  over  the  os  uteri,  its  edge 
will  not  have  been  reached.  But  it  is  seldom  so 
exactly  central  as  this.  Usually  one  edge  is  near  the 
os  utei  i.  In  that  case,  by  separating  the  placenta  all 
round,  you  will  at  one  side  reach  its  edge  and  feel  the 
smooth  membranes,  and  through  them  you  will  be 
able  to  feel  and  identify  the  nearest  part  of  the  foetus. 
Then,  with  the  other  hand  outside  and  the  two  fingers 
inside,  perform  bipolar  version  (see  chapter  xxvi.), 
and  turn  the  child  so  that  a  foot  is  brought  within 
reach  of  the  two  fingers.  Now  rupture  the  mem- 
branes, seize  the  foot  with  the  two  fingers,  and  bring 
it  down  through  the  os  uteri.  Next,  pass  anooseof  clean 
tape  up,  put  it  round  the  ankle  of  the  foot  which  has 
been  brought  down,  and  leave  the  ends  of  the  tape 
hanging  out  of  the  vagina.  When  this  has  been  done 
the  patient  is  safe  from  further  haemorrhage  until  the 
child  has  been  born,  for  if  there  should  be  haemorrhage 
you  can  stop  it  by  pulling  on  the  tape,  which  will 
drag  the  part  of  the  child  over  the  os  uteri  down  upon 
the  l)wer  uterine  segment,,  so  as  to  stop  haemorrhage 
by  its  pressure.  Do  not  pull  the  child  down  unless 
there  be  hemorrhage,  for  it  is  better  that  the  cervix 
should   dilate   slowly   and   naturally  than   be  hastily 


Treatment  of  Placenta  Prmvia. 


323 


forced  open  and  probably  torn.  Leave  delivery  to 
nature  as  much  as  possible,  and  in  most  cases  the 
uterine  contractions  will  force  the  child  down  enough 
to  stop  haemorrhage.  But  should  uterine  contraction 
fail  and  haemorrhage  come  on,  then  resort  to  the 
means  of  stopping  it  which  the  noose  round  the  foot 
gives  you. 

If  the  placenta  be  so  central  that,  after  it  has  been 
separated  as  far  as  the  fingers  will  reach,  yet  you 
cannot  anywhere  feel  the  edge,  push  the  fingers 
through  the  placenta,  and  then  perform  bipolar  version 
and  bring  down  the  foot,  as  has  been  described.  It 
is  more  difficult  to  push  the  fingers  through  the 
stringy  mass  of  the  placenta  than  through  the  mem- 
branes, and  therefore  perforation  of  the  placenta  is 
not  to  be  done  if  it  can  be  avoided. 

Suppose  that  the  os  uteri  will  not  admit  two 
fingers  ;  it  must  be  dilated  until  it  will.  Put  in  two 
or  three  pieces  of  laminaria  side  by  side ;  dilate 
the  cervix  with  Hegar's  dilators ;  or  slowly  and 
gently  stretch  open  the  cervical  canal  with  the 
fingers. 

Champetier's  bag. — The  foregoing  is  the  practice 
that  has  been  proved  by  experience  to  be  good  treat- 
ment in  placenta  praevia.  The  dilating  bag  of  Cham- 
petier  de  Ribes  gives  still  better  results.  The  bag 
can  be  put  in  (if  not  made  of  too  thick  material)  as 
soon  as  the  os  is  big  enough  to  admit  two  fingers.  If 
the  edge  of  the  placenta  can  be  reached,  the  bag 
should  be  pushed  through  the  membranes.  If  not, 
it  should  be  pushed  through  the  placenta  into  the 
amniotic  cavity.  When  it  is  distended  it  forms  a 
cone  filling  the  lower  segment  of  the  uterus,  and 
pressing  all  round  on  the  placental  site.  If  the  bag 
excites  uterine  action,  its  pressure  will  dilate  the  cervix 
and  at  the  same  time  stop  haemorrhage.  If  uterine 
action  fails,  pressure  on  the  bleeding  point  can  be 
maintained  and  dilatation  effected  by  gentle  pulling 
on  the  bag.  Dilatation  by  the  bag  has  the  advantage 
that  the  bag  can  be  put  in  before  the  cervix  is  dilated 


324  Difficult   Labour. 

enough  to  allow  bimanual  vei'sion,  and  thus  the 
manipulations  necessary  to  dilate  up  to  the  point  of 
possible  version  are  reduced.  The  risk  to  the  child 
is  also  less,  as  the  only  danger  to  the  child  is  from 
the  early  separation  of  part  of  the  placenta ;  and  in 
lateral  or  marginal  cases  this  need  not  be  very  great. 
The  danger  from  pressure  on  the  cord  in  extraction 
is  avoided,  as  the  child  can  be  quickly  delivered  when 
the  ba<;  has  done  its  work. 


CHAPTER     XXIV. 

HAEMORRHAGE   AFTER    DELIVERY. 

Can  post-partum  haemorrhage  be  prevented  ? 

—  Much  has  been  written  about  the  production  of  post- 
partum haemorrhage  by  causes  acting  during  preg- 
nancy. It  has  been  said  that  post-partum  haemorrhage 
is  favoured  by  rapidly  following  pregnancies,  poverty, 
want  of  exercise,  over-work,  over-eating,  the  use  of 
stimulants,  over-excitement,  mental  depression.  There 
is  not  a  particle  of  evidence  to  show  that  these  con- 
ditions affect  its  frequency  in  any  way.  Elderly 
primiparity  has  recently  been  said  to  favour  its  oc- 
currence; but  statistics*  show  that  it  does  not.  Over- 
distension of  the  uterus,  and  the  presence  of  tumours 
in  the  uterus,  undoubtedly  lead  to  an  abnormal  course 
of  labour,  and  post-partum  haemorrhage  may  be  one  of 
the  conditions  sometimes  thus  caused.  But  its  oc- 
currence or  not  depends  on  the  way  the  abnormal 
labour  is  managed.  Albuminuria  has  been  said  to 
cause  post-partum  haemorrhage.  Bright's  disease  may 
cause  bleeding  from  the  nose,  and  so  I  suppose  it  may 
cause  bleeding  from  the  uterus  after  delivery ;  but  if 
it  does,  it  does  it'  very  seldom.  Many  doctors  have 
thought  that  they  prevented  post-partum  haemorrhage 
by  dosing  their  patients  during  pregnancy  with  iron, 
strychnine,  quinine,  chloride  of  calcium,  hydrochloric 
acid,  or  other  drugs.  There  is  no  evidence  that  the 
swallowing  of  any  drug  during  pregnancy  will  either 
produce  or  prevent  bleeding  from  the  uterus  after 
delivery.  If  the  patient  needs  a  tonic  during  preg- 
nancy there  is  no  reason  why  she  should  not  have  it ; 
but  whether  after  labour  she  bleeds  too  much  or  not, 

*  Erdmauu,  Archiv.  fur  Gyn.,  Band  xxxix. 


326  Difficult  Labour. 

• 

will  depend  upon  how  the  labour  is  managed.     In 

well  managed  labours  great  post-partum  haemorrhage 

is  rare. 

Causes  of  post-partum  haemorrhage. — The 

causes  of  post-partum  haemorrhage  may  be  divided 
into  three  groups  :  one  comprising  the  vast  majority 
of  cases ;  the  other  two  a  small  minority. 

The  groups  are : 

Common  :  A.  Imperfect  contraction  of  the 
uterus. 

xj         /  B.   Injury  to  the  uterus. 

\  C.  Disease  of  the  blood  or  blood-vessels. 

A.    Haemorrhage   from    imperfect   uterine 

contraction. — The  imperfect  uterine  contraction 
that  causes  post-partum  haemorrhage  is  of  two 
kinds. 

1.  That  which  is  imperfect  because  the  womb  is 

not  empty. 

2.  That  which  is  imperfect  because  the  nervous 

energy  of  the  uterus  is  exhausted. 

1.  Imperfect  Contraction  of   Uterus  because  it 
is  not  Empty. 

Adhesion  of  placenta. — This  was  at  one  time 
thought  to  be  more  frequent  than  is  now  believed. 
Beginners  often  think  that  adhesion  of  the  placenta  is 
commoner  than  it  really  is,  because  (a)  they  fail  to 
distinguish  between  retention  of  the  placenta  in  the 
vagina,  due  to  want  of  skill  in  pressing  it  out,  and 
retention  in  the  uterus  ;  and  (b)  because,  until  they 
find  out  how  rare  adhesion  is,  they  often,  like  many 
of  the  old  accoucheurs,  take  mere  slow  separation  of 
the  placenta  for  retention  by  adhesions.  With  in- 
creasing skill  in  pressing  out  the  placenta,  and  in 
recognising  the  diminution  in  size  of  the  uterus  which 
accompanies  the  expulsion  of  the  placenta  into  the 
vagina,  and  increasing  experience  of  the  great  differ- 
encea  between  different  cases  of  normal  labour,  you 


Adhesion  of  Placenta.  327 

will  come  to  learn  that  adhesion  of  the  placenta  is  a 
rare  thing. 

Morbid  Anatomy. — Though  rare,  morbid  ad- 
hesion of  the  placenta  does  occur.  Cases  have  been 
recorded*  in  which  bits  of  placenta  have  been  so  firmly 
adherent  to  the  uterus  that  even  after  death  it  was 
not  possible  to  detach  them  :  and  on  microscopic  ex- 
amination it  was  found  that  at  these  parts  no  decidua 
serotina  was  to  be  seen.  It  was  replaced  by  tough 
fibrous  tissue  :  and  chorionic  villi  could  be  seen  pene- 
trating the  muscular  tissue  and  venous  sinuses.  This 
may  have  been  the  result  of  inflammation  during 
pregnancy  :  but  in  the  cases  that  have  been  examined' 
there  has  been  no  evidence  of  recent  inflammation. 
We  do  not  yet  know  enough  about  the  decidual 
diseases  that  lead  to  adhesion  of  the  placenta  to  be 
able  to  foretell  or  prevent  such  adhesion. 

Effects. — If  the  placenta  should  be  everywhere 
adherent,  of  course  no  bleeding  can  take  place,  for 
then  no  vessel  can  be  opened.  But  such  cases  are 
infinitely  rare  :  usually  the  adhesion  is  only  partial. 
In  that  case  the  healthy  part  is  separated,  while  the 
adherent  part  remains  attached.  The  uterus  there- 
fore cannot  expel  the  placenta,  and  cannot  properly 
retract  and  contract.     Hence  the  bleeding. 

When  the  adhesion  of  part  of  the  placenta  thus 
leads  to  the  whole  being  retained  in  the  uterus,  the 
fact  that  the  afterbirth  is  not  expelled  at  once  draws 
attention  to  the  cause  of  the  haemorrhage. 

But  another  course  of  events  is  possible.  If  only 
a  small  piece  of  the  placenta  is  adherent,  the  mass  of 
the  placenta  may  be  broken  off  from  it  and  expelled. 
In  that  case  the  little  adherent  bit  of  placenta  may 
prevent  persistent  uterine  retraction,  and  post-partum 
haemorrhage  may  be  the  result.  But  the  uterine  con- 
traction that  has  driven  out  the  bulk  of  the  placenta 
may  continue  in  spite  of  the  retention  of  a  bit.  There 
will  then  not  be  excessive  haemorrhage  at  the  time  of 
labour  and  thus  you  may  at  the  time  overlook  the 

*  Neumann,  Mounts,  filr  Geb.  und  Gyn.,  189G,  Bd.  IV.,  5,307. 


328  Difficult  Labour. 

retention  of  a  small  fragment  of  placenta,  and  only 
find  it  out  when  haemorrhage  occurring  some  hours,  or 
it  may  be  days,  after  delivery,  obliges  you  to  explore 
the  uterus. 

SuCCenturiate  placentae. — Sometimes  a  portion 
of  placenta  is  separated  from  the  rest  by  a  part  of  the 
chorion  destitute  of  villi.  If  the  two  parts  are  nearly 
of  the  same  size,  the  placenta  has  been  wrongly  called 
a  double  placenta  If  there  is  a  small  part  and  a 
large  part,  the  large  part  is  identified  as  the  placenta 
and  the  small  part  is.  called  a  placenta  succenturiata. 
There  may  be  more  than  one  such  island  of  placenta 
separate  from  the  main  mass ;  as  many  as  seven  have 
been  seen.  The  explanation  of  their  occurrence  which 
seems  to  me  best  supported  by  observation,  is  that 
the'  part  bare  of  villi,  which  separates  the  succenturiate 
placenta  from  the  rest,  is  a  part  the  villi  of  which 
have  been  destroyed  by  haemorrhage  into  them  during 
pregnancy.  The  occurrence  of  succenturiate  placentae 
is  clinically  important,  because  one  of  these  may  be 
retained  after  the  bulk  of  the  placenta  has  been  ex- 
pelled, and  may  cause  haemorrhage.  The  retention  of 
an  adherent  bit  of  placenta  can  be  found  out  by 
examining  the  placenta,  in  which  the  gap  left  by  the 
torn-off  piece  will  be  seen.  If  there  is  a  succenturiate 
placenta,  there  will  be  no  gap  in  the  main  mass.  But 
a  piece  of  chorion  will  be  retained  along  with  the 
islet  of  placenta,  and  therefore,  if  you  examine 
the  membranes  as  well  as  the  placenta,  you  will  in 
such  cases  detect  the  retention  of  a  piece  of  membrane. 
You  will  also  see  the  two  vessels  which  supplied  the 
placenta  succenturiate  with  blood  running  off  the  edge 
of  the  placenta.  If,  however,  the  chorion  has  been 
separated  from  the  amnion  during  delivery  and  torn 
in  extraction,  it  will  be  practically  impossible,  without 
putting  the  hand  into  the  uterus,  to  be  sure  that 
there  is  not  a  bit  of  choilon  retained.  Therefore,  if 
called  to  a  case  in  which  a  bit  of  placenta  or  mem- 
brane has  been  retained,  do  not  think  that  the 
attendant  during  labour  is  necessarily  to  be  blamed. 


Hour-glass  Contraction  of  the  Uterus.    329 
Retention  of  membrane  in  the  uterus  will,  to 

an  extent  dependent  on  the  size  of  the  retained  piece, 
prevent  proper  uterine  retraction,  and  therefore  cause 
postpartum  haemorrhage.  If  by  the  care  of  the 
attendant  the  uterus  is  made  to  retract  and  contract 
after  delivery,  notwithstanding  the  piece  of  membrane 
within  it,  secondary  post-partum 
haemorrhage  is  likely  to  occur 
later.  The  membrane,  the  re- 
tention of  which  gives  trouble, 
is  the  chorion.  The  decidua  is 
so  thin  and  friable  that  its  re- 
tention is  of  no  consequence ;  and 
the  amnion  is  so  tough  that  the 
placenta  generally  pulls  it  away 
entire.  Retention  of  chorion  is 
favoured  both  by  too  early  and 
by  too  late  rupture  of  membranes. 
Too  early  rupture  of  the  mem- 
branes prevents  that  separation 
of  the  chorion  from  the  uterus 
which  should  take  place  as  the 
bag  of  membranes  moves  on  into 
the  os.  If  rupture  takes  place 
abnormally  late,  the  chorion  may 
give  way,  the  amnion  move  on 
through  it,  and  the  amnion  and  chorion  become 
separated.  It  is  believed  that  retention  of  chorion 
may  be  produced  by  endometritis,  leading  to  too  close 
adhesion  between  the  decidua  and  chorion. 

Hour-glass  contraction  of  the  uterus*  is  a 

rare  condition,  in  which  the  uterus  seems  to  be  divided 
into  two  cavities  by  a  circle  of  contraction,  so  that 
its  shape  has  been  thought  like  that  of  an  hour-glass. 
The  upper  cavity  contains  the  placenta  (Fig.  124).  It 
is  generally  believed  that  the  circle  of  contraction  is 
identical  with  the  retraction  ring,  or  ring  of  Bandl. 
The  part  above  this  ring  is  prevented  from  complete 

*  For  reports  of  well-observed  cases  see  papers  by  Freund  and 
Ahlfeld,  Zcit.fUr  Geb.  und  Gyn.,  Bd.  xvi. 


Fig.  124.— Hour-glass  Con- 
traction of  the  Uterus. 
(After  Tyler  Smith.) 


33°  Difficult  Labour. 

contraction  by  the  placenta  within  it  (hence  the  late 
Dr.  Matthews  Duncan  spoke  of  this  condition  as 
"  hour-glass  relaxation  ")  ;  its  lower  boundary  is  con- 
tracted below  the  placenta ;  the  cervix  and  possibly 
the  lower  segment  of  the  uterus  hang  down  loosely 
below  the  retraction  ring.  Cases  have  been  described 
in  which  it  was  thought  that  the  ring  of  retraction 
was  too  high  up  to  be  the  internal  os ;  but  such  cases, 
if  they  occur,  are  so  rare  that  we  know  nothing  about 
their  production.  The  uterus  in  so-called  hour-glass 
contraction  is  a  uterus  that  is  contracted  but  has  not 
yet  expelled  the  placenta.  The  theoretical  explana- 
tion is  that  the  circular  fibres  of  the  lower  uterine 
segment,  which  ought  to  be  inhibited  during  labour, 
are  not  inhibited  ;  their  contraction  morbidly  persists. 
We  know  nothing  as  to  why  inhibition  is  morbidly 
absent  in  these  cases.  The  placenta  may  or  may 
not  be  adherent.  If  it  be  not,  then,  if  you  wait,  the 
placenta  will  be  expelled.  If  it  be  adherent,  this 
hour-glass  condition  will  continue.  The  haemorrhage 
is  not  so  great  as  in  atony  of  the  uterus,  nor  is  the 
uterine  body  completely  relaxed ;  but,  if  the  placenta 
be  partly  separated  and  not  expelled,  draining  of  blood 
will  go  on  until  the  uterus  is  emptied  and  can  con- 
tract and  retract. 

This  condition  is  not  difficult  of  diagnosis.  You 
find  that  the  uterus  continues  hard  and  large,  and, 
half  an  hour  or  more  after  delivery,  although  the 
uterus  is  felt  by  the  abdomen  to  contract,  it  does  not 
diminish  in  size,  and  the  placenta  does  not  come  away. 
Examine  by  the  vagina  and  you  will  feel  the  cord 
passing  through  the  firm  ring  of  contraction. 

If  the  patient  has  lost  more  blood  than  ought  to 
be  the  case,  it  will  not  be  wise  to  wait  and  see  if  the 
uterus  will  expel  the  placenta,  although  in  most  cases 
it  will  do  this  if  time  be  given  j*  but  the  patient  may 

*  I  saw  a  case  once,  with  Dr.  F.  J.  Reilly,  in  which  the  placenta 
was  retained  for  several  days  in  utero.  While  we  were  discussing 
arrangements  for  anaesthetising  the  patient  and  removing  the 
placenta,  it  was  spontaneously  expelled. 


Hour-glass  Contraction  of  the  Uterus    331 

in  the  meantime  lose  enough  blood  to  make  her  con- 
valescence slow,  or  even  to  cause  death. 

The  treatment  is  to  pass  the  hand  into  the 
uterus,  with  the  tips  of  the  fingers  pressed  together  so 
as  to  give  the  hand  the  shape  of  a  cone.  Grasp  the 
body  of  the  uterus  with  the  other  hand  on  the 
abdomen,  and  press  it  downwards  and  backwards. 
The  object  of  such  counter-pressure  is  (1)  to  push  the 
cervix  down  within  easier  reach  of  the  internal  hand, 
and  (2)  to  prevent  the  uterus  from  being  torn  away 
from  the  vagina.  With  this  precaution,  by  steady, 
gentle  pressure  get  the  hand  into  the  uterus,  and 
press  the  tips  of  the  fingers  up  between  the  uterus 
and  placenta,  breaking  down  any  abnormal  adhesion 
that  may  exist,  until  your  fingers  have  reached  the 
top  of  the  placenta.  Then  hook  the  fingers  over  the 
upper  edge  of  the  placenta  and  bring  it  away.  Aim 
at  getting  the  placenta  away  entire  if  possible ;  for 
if  you  break  the  placenta  the  chance  of  leaving  a 
small  piece  behind  is  increased.* 

Treatment  of  adherent  placenta. — Whenever 

it  is  inferred,  from  the  slowness  of  its  expulsion  from 
the  uterus,  that  the  placenta  is  adherent,  it  should  be 
removed  in  the  way  just  described.  Where  there  is 
no  retraction  ring  to  be  dilated,  the  removal  of  the 
placenta  will  be  easier. 

The  cases  which  have  just  been  considered  are 
very  important,  because  in  them  no  treatment  of 
the  haemorrhage  is  effective  unless  the  cause  is  re- 
cognised ;  and  removal  of  the  cause  usually  stops  the 
haemorrhage. 

2.  Imperfect  Contraction  of  Uterus  because  its 
Contractile  Energy  is  exhausted. 

In  these  most  terrible  cases  haemorrhage  occurs 
because  the  nervous  energy  of  the  uterus  is  enfeebled 

*  I  have  once  only  met  with  a  placenta  so  adherent  that  I 
could  not  remove  it  entire,  but  had  to  scrape  it  off  and  get  it  away 
in  small  fragments.  The  patient,  thanks  to  antiseptic  douches, 
got  well. 


332  Difficult  Labour. 

or  exhausted,  and  not  because  there  is  anything 
retained.  Here  the  patient's  safety  depends  upon  our 
success  in  exciting  the  contraction  and  retraction  of 
the  uterus,  and  keeping  the  flooding  in  abeyance  until 
the  uterus  has  recovered  its  nervous  energy. 

The  causes  of  uterine   atony. — The  surest 

way  to  produce  post-partum  haemorrhage  is  to  drag 
out  the  child  or  the  placenta  at  a  time  when  con- 
traction is  absent.  Methods  of  hastening  delivery — 
forceps,  breech  or  foot  traction — should  only  assist  the 
action  of  the  uterus,  never  replace  it.  Weak  uterine 
contractions,  not  strong  enough  to  expel  the  child 
within  the  usual  limit  of  time,  may  be  quite  strong 
enough  to  expel  the  placenta  and  compress  th6 
uterine  veins.  But  if  the  delay  in  delivery  is  due 
to  "  temporary  passiveness," — otherwise  known  as 
"secondary  uterine  inertia" — extraction  of  the  child 
during  this  condition  is  almost  certain  to  be  followed 
by  haemorrhage,  because  uterine  retraction  and  con- 
traction are  absent.  It  is  true  that  extraction  during 
absence  of  pain  is  not  invariably  followed  by 
haemorrhage.  This  is  because  uteriue  contraction  is 
(a)  intermittent,  and  (6)  provoked  by  reflex  irritation. 
If  since  the  last  uterine  contraction  a  time  has  elapsed 
sufficient  to  almost  completely  restore  the  contractile 
energy  of  the  uterus,  the  effect  of  artificial  delivery 
will  be  to  provoke  uterine  contraction  a  little  sooner 
than  it  would  otherwise  have  taken  place,  and  no 
harm  will  happen.  But  if  the  nervous  energy  of  the 
uterus  has  not  been  recuperated,  post-partum  haemor- 
rhage will  surely  follow  the  extraction  of  the  child. 
The  only  way  of  being  certain  that  the  uterus 
possesses  sufficient  contractile  energy  to  safely  accom- 
plish the  third  stage  of  labour,  is  to  wait  for  uterine 
contraction  before  you  begin  to  extract  the  child.  If 
the  uterus  is  not  acting  there  can  be  no  necessity  for 
hasty  delivery,  for  damage  from  pressure  cannot 
happen  while  the  uterus  is  inactive. 

The  principle   not   to   deliver   in   the   absence   of 
uterine  contraction  is  the  first  point  in  the  prevention 


Prevention  of  Postpartum  Hemorrhage.  333 

of  post-partum  haemorrhage.  Do  not  pull  away  the 
placenta  without  waiting  for  uterine  contraction. 
Give  time  for  the  proper  detachment  of  the  membranes, 
and  look  at  them  to  see  that  the  whole  of  the  chorion 
has  come  away.  If  the  placenta  is  squeezed  or  pulled 
out  before  the  membranes  are  separated,  a  bit  of 
chorion  may  be  stripped  off  the  amnion  instead  of  off 
the  uterus,  and  so  be  retained  and  afterwards  cause 
'haemorrhage.*  However  natural  the  delivery  of  the 
placenta  and  membranes,  it  is  important  to  see  that 
the  whole  of  the  chorion  is  removed.  Put  the 
placenta  in  a  basin  of  water,  uterine  surface  upwards, 
The  villi  will  float  up,  so  that  you  can  see  at  a  glance 
if  any  part  of  it  is  missing. 

If  due  time  is  given  for  the  natural  separation 
and  expulsion  of  the  placenta  and  membranes  from 
the  uterus,  it  matters  very  little  whether  the  placenta 
is  pushed  out.  of  the  vagina  by  pressure  from  above 
or  pulled  out  by  the  cord.  The  advantage  of  the 
Dublin  (otherwise  called  Crede's)  method  of  delivering 
the  placenta  from  the  vagina  is  that  it  ensures  the 
prompt  discovery  and  treatment  of  failure  of  uterine 
action. 

These  two  points — care  not  to  extract  the  child  or 
the  placenta  when  the  uterus  is  not  contracting,  and 
close  supervision  of  the  third  stage  of  labour — are  the 
chief  precautions  for  the  prevention  of  haemorrhage. 

Treatment. — The  modes  of  stopping  bleeding 
after  labour  may  be  divided  into  three  groups,  accord- 
ing to  their  principal  aim,  which  is  :-•  — 

1.  To  make  the  uterus  contract. 

2.  To  clot  the  blood. 

3.  To  compress  the  bleeding  veins. 

In  all  cases  first  try  to  make  the  womb  contract — 
in  most  you  will  succeed.  Oases  are  fortunately  rare 
in  which  the  womb  will  not  contract,  and  in  which 
you  have  to  do  something  else. 

There  are  three  ways  of  making  the  uterus  con- 
tract, namely  : — 

*  See  Kunge,  Med.  Times  and  Gazette,  1S80,  vol.  ii.  p.  50S. 


334  Difficult  Labour. 

1.  Direct  stimulation. 

2.  Indirect  stimulation. 

3.  Drug  stimulation. 

1.  Direct  Stimulation.— (a)  Knead  the  uterus 
with  the  hand  outside.  Kneading  the  uterus  through 
the  abdominal  wall  comes  first,  because  it  is  the 
method  of  treatment  that  can  be  adopted  most  quickly. 
Your  hand  is  always  ready,  while  everything  else 
takes  time  to  prepare.  It  is  almost  always  successful* 
for  the  time,  and  in  the  slighter  cases  its  repetition 
at  intervals  is  enough. 

(b)  Hand  inside.  But  in  some  cases  the  response 
of  the  uterus  to  stimulation  from  outside  is  not 
lasting.  Then  pass  your  hand  into  the  relaxed 
uterus.  This  not  only  stimulates  the  uterus,  but  by 
it  you  gain  help  in  diagnosis  and  prevention.  The 
business  of  the  intra-uterine  hand  is  to  find  out  if 
there  be  anything  in  the  womb  which  is  causing 
the  bleeding,  such  as  retained  placenta,  membrane, 
clots,  or  a  tumour,  and,  if  there  be,  to  remove  it.  If 
you  have  removed  the  cause,  continued  stimulation 
from  outside  will  generally  secure  continuance  of 
uterine  contraction. 

(c)  Injection  of  hot  water.  But  the  contraction 
provoked  by  the  contact  of  your  hand  with  the  inside 
of  the  womb  may  not  last.  The  repeated  introduction 
of  your  hand  is  undesirable.  The  next  thing  to  be 
done  is  to  inject  hot  water  into  the  uterus.  This 
directly  provokes  contraction,  and  does  good  in 
another  way  ;  it  washes  out  loose  clots,  bits  of  mem- 
brane, etc.,  small  enough  to  elude  your  hand,  and 
yet  better  out  of  the  uterus.  It  seems  as  if  the 
hotter  the  water  the  greater  the  effect.  Water  in 
which  you  can  bear  to  immerse  your  hand  will  not 
injure  the  tissues,  although  it  may  be  a  little  hotter 
than  the  patient  likes.  Do  not,  therefore,  if  the  case 
be  urgent,  lose  time  in  taking  the  temperature  of  the 
water  ;  your  hand  (not  finger)  is  sensitive  enough. 

(d)  Cold  water  or  ice.  Instead  of  hot  water,  cold 
or  iced  water  may  be  used,  or  a  lump  of  ice  may  be 


Stimulation  of  Uterus.  335 

put  inside  the  uterus  or  the  vagina.  But  ice  is  not 
generally  available  when  wanted,  whilst  hot  water  is 
always  ready  in  the  lying-in  room,  and,  to  an  ex- 
hausted patient,  warmth  is  more  grateful  than  cold. 

(e)  Electricity.  Electricity  has  been  recommended, 
and  doubtless  a  powerful  current  would  stimulate 
the  uterus  as  it  does  any  other  muscle.  But  even  if 
you  should  have  with  you  a  battery,  the  time  con- 
sumed in  getting  the  electrodes  fit  for  action  will  be 
better  spent  in  using  other  and  quicker  ways  of 
stopping  the  bleeding. 

2  Reflex  Stimulation. — Two  modes  of  reflex 
stimulation  are  in  common  use,  which  act  through 
the  nerves  (a)  of  the  skin,  (b)  of  the  breast,  (a)  Ice 
or  cold  wet  napkins  to  the  vulva,  slapping  the 
abdomen  with  a  cold  wet  cloth,  and  pouring  cold 
water  on  the  abdomen,  are  familiar  and  old  re- 
medies. They  cause  reflex  contractions  of  the 
uterus.  But  drenching  with  cold  water  makes  the 
patient  uncomfortable,  and  depresses  her  strength,  as 
Madame  La  Chapelle  pointed  out.  The  milder 
measure  of  a  cold  wet  cloth  is  less  objectionable,  but 
it  is  not  superior  in  effect  to  kneading  the  uterus  with 
the  hand.  But  if  you  are  tired  of  kneading,  or  have 
to  do  something  else  with  your  hands,  a  cold  wet 
cloth  applied  by  the  nurse  may  be  a  useful  temporary 
substitute,  (b)  Putting  the  child  to  the  breast  is  so 
harmless  that  this  should  always  be  done.  But  the 
time  generally  taken  up  in  doing  this  prevents  it 
from  being  of  immediate  use,  although  it  is  valuable 
as  a  means  of  keeping  up  the  contractions  procured 
by  kneading  the  uterus. 

3.  Drug  Stimulation. — Ergot.  There  is  one 
drug,  and  only  one,  which  produces  uterine  contrac- 
tion and  retraction,  and  that  is  ergot.  Other  drugs 
have  been  advised,  and  good  results  reported  from 
them,  but  there  is  none  that  approaches  ergot  in 
power.  But  in  the  worst  cases  we  cannot  wait  for 
the  absorption  of  ergot,  for  even  when  the  drug  or 
one  of  its  derivatives  is  injected  under  the  skin,  there 


33$  Difficult  La  four. 

is  still  time  for  fatal  haemorrhage  before  its  action  on 
the  uterine  muscle  begins ;  and  the  worst  cases  of 
haemorrhage  are  those  in  which  the  contractile  power 
of  the  uterus  is  exhausted,  and  then  even  ergot  fails. 
Ergot  is  invaluable,  but  its  chief  uses  are  (a)  as  a 
prophylactic,  given  immediately  after  the  birth  of  the 
child,  and  (b)  after  bleeding  has  stopped,  to  make 
tonic  the  contraction  produced  by  other  means. 

Tonic  spasm  of  the  uterus  without  retraction. 

■ — There  is  a  rare  form  of  post-partum  haemorrhage, 
in  which  the  body  of  the  uterus  becomes  hard  and 
rigid,  but  its  cavity  is  not  closed.  There  is  spasm, 
but  not  retraction.  This  condition  may  follow  the 
administration  of  ergot,  but  also  occurs  without  it. 
There  is  continuous  bleeding,  which  goes  on 
until  syncope  is  produced ;  then  the  spasm 
relaxes,  and  the  bleeding  can  be  stopped  by  the 
means  of  procuring  uterine  contraction,  which  I 
have  just  described.  The  treatment  of  the  spasm  is 
to  anaesthetise  the  patient  quickly,  in  order  to  relax 
spasm.* 

Treatment   of    exhaustion    of   contractile 

power. — The  worst  cases  of  post-partum  haemor- 
rhage are  those  in  which  the  contractile  power  of  the 
uterus  is  exhausted,  and  no  kind  of  stimulant  will 
procure  tonic  contraction.  We  must  here  rely  either  on 
pressure,  on  blood-clotting,  or  on  a  combination  of  both. 

Perchloride  of  iron. — The  injection  of  per- 
chloride  of  iron  solution  (1  in  6)  stimulates  the  uterus 
to  conti'act  and  clots  the  blood.  It  is  the  clotting  that 
is  valuable,  for  the  stimulant  effect  can  be  got  by  other 
means.  The  cases -in  which  the  clotting  is  required 
are  those  in  which  the  uterus  has  lost  its  contractile 
power  ;  therefore  you  leave  off  trying  to  make  it  con- 
tract, and  act  directly  on  the  blood.  This  treatment 
has  been  advocated  by  Robert  Barnes. 

The  objections  to  it  are,  first,  that  it  is  dangerous  : 

9  See  Matthews  Duncan,  Obst.  Trans.,  vol.  xxix.,  p.  359 ;  see 
also  Gibbons,  Comptes  Rendus,  Congres  periodique  Internationale 
de  Gipiecologie  et  d'1 Obstetrique,  1894;  and  Leahy,  Lancet,  August 
3rd,  1895. 


Perchloride   of  Iron.  337 

(a)  Death  has  occurred  from  pumping  a  quantity 
of  fluid  into  the  uterus;  for  the  uterus  will  not  tolerate 
sudden  distension,  although  it  will  submit  to  gradual 
stretching.  To  avoid  this,  use  a  double-channelled 
tube,  or  put  two  fingers  in  the  cervix  with  the  tube 
between  them.  Either  precaution  lessens  but  does 
not  remove  the  danger.  Bleeding  is  still  going  on, 
the  injection  clots  the  blood,  and  the  clots  may  be 
carried  down  by  the  reflux  and  stop  up  the  channel 
for  the  back  flow  of  fluid. 

(6)  A  clot  may  be  carried  from  a  uterine  vein  into 
a  pulmonary  vein,  plug  it,  and  thus  cause  death. 
A  clot  formed  artificially  in  a  vessel  with  an  open 
channel  is  quite  a  different  thing  from  one  naturally 
formed  in  a  vessel  the  walls  of  which  are  firmly 
pressed  together. 

(c)  The  iron  solution  may  run  along  the  Fallopian 
tube  into  the  peritoneal  cavity  and  set  up  peritonitis. 
(The  two  latter  accidents  have  not  as  yet  occurred 
from  the  injection  of  iron  for  post-partum  haemorrhage, 
but  they  have  resulted  from  its  intra-uterine  injection 
for  haemorrhage  of  other  kinds.) 

(d)  If  these  immediate  dangers  are  escaped,  the 
uterus  is  not  left  in  a  physiological  condition.  It 
ought  to  be  contracted  and  empty.  It  is  left  dilated 
and  full  of  clot.  This  clot  may  decompose,  and  thus 
the  patient  has  an  additional  chance  of  septicaemia. 

Secondly,  the  injection  of  perchloride  of  iron  is 
not  always  successful.  In  the  St.  Thomas's  Hospital 
Reports,  between  1872  and  1880,  I  find  five  failures 
recorded.  Galabin  *  states  that  out  of  twelve  cases 
in  the  Guy's  Charity  in  which  the  ferric  solution  was 
used,  five  died.  It  may  be  urged  that  death  does  not 
always  mean  failure*  to  arrest  haemorrhage,  for  the 
patient  may  have  died  from  the  loss  of  blood  which 
had  occurred  before  the  treatment  was  used.  But  in 
a  paper  by  Pollard  f  I  find  three  cases  in  which 
haemorrhage  recurred  after  the  iron  had  been  injected. 

*  "Midwifery,"  1st  edition,  p.  691. 
W 3(3        t  Brit.  Med.  Journal,  1880,  vol.  i. 


338  Difficult  Labour. 

Two  others  are  recorded  in  the  Obstetrical  Society's 
Transactions.*  My  conclusion  is  that  the  injection 
of  perchloride  of  iron,  although  its  effect  is  to  check 
haemorrhage,  is  neither  a  safe  nor  a  certain  mode 
of  treatment. 

Plugging  the  Uterus. — A  new  treatment  has 
lately  come  from  Germany — namely,  plugging  the 
uterus  with  iodoform  gauze.  It  is  claimed  that  by 
packing  the  uterus  with  gauze  the  flow  of  blood  from 
the  vessels  is  mechanically  hindered,  and  that  the  pre- 
sence of  the  gauze  provokes  energetic  uterine  contrac- 
tion. It  will  be  evident  also  that  the  threads  of  the 
gauze  furnish  a  surface  well  adapted  to  provoke  clot, 
ting  of  the  blood.  Its  advocates  say  that  the  bleeding 
is  stopped  by  the  powerful  contraction  of  the  uterus 
on  the  gauze  plug,  which  is  a  continuously  acting 
stimulant.  They  say,  further,  that,  if  you  have  gauze 
■with  you,  you  are  saved  the  trouble  of  exact  diagnosis 
of  the  cause  of  bleeding,  for  gauze  plugging  is  the 
best  way  of  stopping  haemorrhage  from  lacerations  of 
the  canal  (except  in  the  case  of  tears  of  the  vulva, 
which  can  be  easily  seen),  and  therefore  in  haemorrhage 
of  uncertain  origin  the  best  plan  is  to  plug  both  vagina 
and  uterus.  Duhrsscn  t  (to  whom  we  are  indebted 
for  this  mode  of  treatment)  recommends  prophylactic 
plugging — that  is,  plugging  as  soon  as  there  is  a 
threatening  of  haemorrhage  instead  of  waiting  for 
haemorrhage  to  become  serious.  Granted  that  the 
uterus  is  to  be  plugged,  there  is  no  better  way  of 
doing  it  than  with  iodoform  gauze. 

Any  treatment  of  postpartum  haemorrhage  that 
is  largely  used  in  slight  cases  as  a  prophylactic  will 
show  a  great  percentage  of  lives  apparently  saved,  for 
cases  of  dangerous  haemorrhage  are  rare.  We  must 
judge  the  effect  of  treatment  of  this  haemorrhage 
rather  by  the  fewness  of  failures  than  by  the  number 
of  apparent  successes.     Death  from  atonic  haemorrhage 

*  Vol.  xx. 

t  SamnUung  kiln.  Vort.  Leipzig,  No.  317. 


Compression  of  the    Uterus.  339 

has  taken  place  in  spite  of  the  plugging.  The 
introduction  of  the  gauze  has  a  danger  of  its  own. 
Sudden  death  has  taken  place  from  entrance  of  air 
into  a  uterine  vein  while  the  gauze  was  being  put  in. 
This  treatment,  therefore,  is  neither  certain  nor  safe. 
It  is,  like  the  injection  of  a  styptic,  unphysiological, 
for  the  uterus  cannot  be  completely  contracted  while 
the  gauze  is  inside  it. 

Continuous  Compression. — If  the  uterus  can  be 
got  to  contract,  and  remains  retracted  and  contracted, 
bleeding  will  stop.  When  the  uterus  responds  by 
vigorous  contraction,  either  to  iron  injection  or  to 
gauze  packing,  it  will  respond  to  other  means.  The 
worst  cases  are  those  in  which  nothing  will  procure 
tonic  contraction.  Here  the  only  remedy  is  con- 
tinuous compression. 

The  uterus  is  too  large  to  be  compressed  by  one 
hand.  Various  modes  of  compression  have  been 
advised.  One  is  to  press  the  uterus  backwards, 
with  your  hand  in  front  of  it,  so  as  to  compress  it 
betAveen  the  hand  and  the  spinal  column.  But  the 
spine  forms  a  convexity  with  a  hollow  on  each  side, 
and  the  uterus,  when  pressed  back  against  it,  is  apt 
to  slip  to  one  side  of  the  spine,  into  a  place  where  it 
cannot  be  so  well  compressed.  Another  suggestion 
is  to  put  your  hand  behind  the  uterus,  and  compress 
it  between  the  symphysis  pubis  and  the  hand.  Here 
the  pressure  of  the  symphysis  is  limited  to  a  small 
area  of  the  uterus. 

It  has  been  advised  to  combine  the  two  hands  by 
putting  one  hand  in  the  uterus  and  the  other  outside. 
This  has  been  varied  by  substituting  for  the  internal 
hand  a  dilated  bag.  Thus  the  uterus  is  compressed 
all  round,  within  and  without.  But  the  objections  to 
the  use  of  iron  to  clot  the  blood  and  to  plugging  the 
uterus  with  gauze  apply  with  greater  force  to  this 
proposal.  The  uterus  cannot  contract  properly  with 
the  hand  or  an  inflated  bag  within  it ;  and  the  pro- 
curing of  uterine  redaction  and  contraction  must 
be  the  final  aim  of  all  your  treatment,  for  by  it  alone 


340  Difficult  Labour. 

can  haemorrhage  be  permanently  stopped.  You  get 
by  this  means  temporary  compression  at  the  expense 
of  hindering  the  permanent  natural  compression  which 
you  want.  There  are  other  objections — the  unavoid- 
able bruising  of  the  uterus,  and  the  keeping  open  a 
channel  through  which  germs  of  disease  may  get  inside 
the  wound. 

The  right  way  is  to  compress  the  uterus  between 
ane  hand  in  the  vagina  and  the  other  on  the  abdomen. 
In  the  left  lateral  position  the  left  hand  will  naturally 
be  used  internally,  the  right  outside.  The  internal 
hand  may  be  laid  flat  (as  suggested  by  Hamilton,  of 
Falkirk*),  the  body  of  the  uterus  being  opposed  to 
the  palm,  the  cervix  lying  between  the  parted  fingers. 

Zweifelf  has  advised  that  the  cervix  be  pressed 
forwards  with  the  fingers  so  as  forcibly  to  anteflex  the 
uterus.  Thus  the  canal  is  kept  so  bent  that  blood 
cannot  get  out.  But  there  is  no  benefit  in  keeping 
blood  in  the  uterine  cavity.  We  want  to  compress 
the  vessels  in  the  uterine  wall,  so  that  blood  may  not 
flow  into  the  cavity.  If  such  bleeding  has  taken  place, 
the  effused  blood  will,  in  proportion  to  its  amount, 
hinder  uterine  contraction,  if  it  be  thus  retained. 
Blood  effused  into  the  uterine  cavity  should  be  ex- 
pelled from  it,  not  kept  pent  up  within  it. 

The  best  way  of  firmly  compressing  the  uterine 
body  is  to  bend  the  fingers  of  your  left  hand  into  the 
palm,  and  grasp  the  uterine  body  between  your  right 
hand  on  the  abdominal  wall  and  the  firm  resisting 
surface  formed  by  the  closed  fingers  and  ball  of  the 
thumb  of  your  left  hand  (Fig.  125).  By  this  use  of  the 
hands  the  whole  of  the  uterine  body  can  be  firmly 
compressed,  and  clots  can  be  squeezed  out  through 
the  cervical  canal,  which  is  not  blocked  up,  as  it  is  in 
Zweifel's  method.  This  method  brings  with  it  no  risk 
of  injury  to  the  uterus,  offers  no  increased  facilities 
for  the  entry  of  germs,  and  secures  the  maintenance 
of  one  essential  condition  for  permanent  uterine  re- 

*  Ed.  Med.  Journal,  1S0L 
t  Ucourtahulfc. 


Compress/on  of   the    Uterus. 


34i 


traction  and  contraction — namely,  an  empty  uterus. 
The  pressure  need  not  be  more  forcible  than  is  needed 
to  press  the  uterine  walls  together.  It  is  a  little 
irksome  to  keep  it  up,  but  it  can  be  maintained  quite 
long  enough  for  the  blood  in  the  vessels  to  clot.  It  is 
not  more  irksome  than  the  repeated  manipulations  and 
the  anxious  watching  of  their  effect  which  other  less 
certain  modes  of  treatment  involve. 

In  short,  when  the  uterus  will  not  contract,  the 


Fig.  125.— How  to  compress  the  Uterus  to  stop  post-partum  Haemorrhage. 


only  thing  that  can  be  relied  on  is  the  maintenance 
of  firm  compression.  By  "  compression  "  I  mean  not 
simply  kneading  the  uterus  to  make  it  contract,  but 
firmly  and  continuously  compressing  the  uterus,  just  as 
a  surgeon  would  compress  a  vein  wounded  during  au 
operation.  Do  not  postpone  this  until  after  repeated 
failure  of  attempts  to  get  contraction ;  but  as  soon  as 
ever  it  is  clear  that  stimulation  fails  to  produce  lasting 
contraction,  steadily  compress  the  uterus  and  maintain 
pressure  until  it  can  be  relaxed  without  bleeding 
occurring. 

Pressure  on  the  aorta  has  been  used  to  stop  post- 


342  Difficult  Labour, 

partum  haemorrhage.  But  pressui'e  directly  on  the 
bleeding  part  is  better. 

B.       HEMORRHAGE    FROM    INJURY   TO    THE    UTERUS. 

The  injuries  to  the  uterus  that  cause  post-partum 
haemorrhage  are  of  two  kinds  : — 

(a)  Laceration  of  the  cervix. 

(b)  Inversion  of  the  uterus. 

(a)  Laceration  of  the  cervix,  so  extensive  as  to 

cause  dangerous  haemorrhage  after  the  birth  of  the 
child,  is  very  rare,  although  the  cervix  is  torn  in 
almost  every  first  labour,  and  in  many  labours  which 
are  not  the  first.  Lacerations  of  the  body  of  the 
uterus  bleed,  and  such  ruptures  may  extend  down  into 
the  cervix,  but  in  these  cases  the  child  is  generally  not 
delivered,  so  that  most  of  the  bleeding  is  not  post- 
partum. The  ordinary  tears  of  the  cervix  extend 
from  below  upwards,  and  result  from  excessive  action 
of  the  dilating  force,  so  that  the  cervix  tears  instead 
of  dilating.  The  larger  the  os,  the  more  powerful  is 
the  dilating  action  of  the  part  pressed  into  it,  and 
the  thinner  the  rim  of  the  os,  the  more  easily  is  it 
torn.  Most  of  these  tears  stop  at  the  insertion  of  the 
vagina,  because  the  presenting  part  does  not  usually 
press  strongly  enough  into  the  cervix  to  tear  it  until 
the  vaginal  insertion  is  fully  or  nearly  fully  dilated. 

Tears  only  affecting  the  vaginal  portion  do  not 
cause  bleeding  which  is  serious  in  amount.  But 
sometimes  the  tear  extends  beyond  the  vaginal  portion, 
up  to  or  even  through  the  internal  os.  A  tear  ex- 
tending as  high  as  this  may  involve  a  considerable 
branch  of  the  uterine  artery.  Tears  so  large  as  this 
hardly  ever  occur  in  labour  completed  by  the  natural 
forces.  They  happen  when  the  accoucheur,  to  get  a 
foetus  through  an  imperfectly  dilated  cervix,  adds 
vigorous  pulling  to  a  strong  pain.  Such  a  tear  is 
also  likely  to  happen  when  dilatation  of  the  cervix 
is  hindered  by  scar  tissue.  The  resistance  of  the 
scar  provokes  stronger  uterine  action  than  usual, 
and  then,  when  at  length  the  scar  does  give  way,  the 


Lacerations  of   Cervix.  343 

unusual  strength  of  the  uterine  contraction  that  tore 
the  scar  across  may  rend  the  cervix  to  a  higher  level 
than  any  ordinary  pain  would  do. 

The  diagnosis  of  this  unusual  kind  of  haemor- 
rhage is  not  difficult.  It  rests  upon  this  fact :  that 
bleeding  from  the  placental  site  is  always  stopped  by 
retraction  of  the  uterus.  If,  therefore,  you  have 
got  firm  persistent  retraction  and  contraction  of  the 
uterus,  and  still  there  is  bleeding,  it  probably  comes 
from  a  torn  cervix.  The  bleeding  from  a  torn  cervix 
is  insignificant  compared  with  that  from  a  relaxed 
uterus,  and  uterine  contraction  will  often  stop  the 
bleeding  from  a  laceration.  Therefore,  in  any  case 
of  post-partum  haemorrhage,  the  first  aim  of  treat- 
ment is  to  get  uterine  contraction.  This  done,  and 
bleeding  still  going  on,  think  of  laceration  of  the 
cervix  ;  make  your  hand  aseptic,  pass  it  into  the 
vagina,  and  feel  the  state  of  the  cervix.  The  cervix 
after  delivery  feels  very  soft  and  uneven,  so  that 
without  carefully  tracing  it  all  round,  a  tear  will  not 
be  easily  detected. 

Treatment  — These  cases  are  exceedingly  rare. 
The  treatment  must  be  applied  to  the  bleeding  spot. 
There  are  three  ways  of  doing  this.  You  may  have 
to  use  the  first  as  a  makeshift.  It  is  to  piny  the 
vagina,  stuffing  the  plugging  material  more  especially 
into  the  tear.  Iodoform  gauze  is  the  best  material  to 
plug  with,  but  if  you  have  not  this  with  you,  use 
anything  clean  that  you  can  get,  taking  care  to  make 
it  aseptic.  This  is  not  the  best  treatment,  but  you 
can  always  get  something  to  plug  with,  and  you 
may  not  have  with  you  what  is  needful  for  more 
effective  treatment.  The  second  is  to  apply  a  styptic. 
Swab  the  part  with  a  solution  of  perchloride  of 
iron,  1  in  6,  or  stuff  wool  or  lint,  soaked  in  this 
solution,  into  the  rent.  This  is  clumsy  treatment. 
We  never  trust  to  styptics  in  bleeding  from  wounds 
that  we  can  see. 

The  proper  treatment  is  to  stitch  up  the  tear. 
Seize    the    cervix   uteri   with   a  volsella    and    pull 


344  Difficult  Labour. 

it  down  to  the  vulva.  Or  get  someone  to  press, 
by  the  abdomen,  the  uterus  down  as  far  as  pos- 
sible, to  bring  it  within  easy  reach.  Pass  in  two 
or  four  fingers  of  your  left  hand  up  to  the  top 
of  the  tear.  With  your  right  hand  pass  up  a 
threaded  needle  in  the  holder,  guarding  its  point 
with  your  left  hand,  and  pass  a  stitch  through 
the  two  sides  of  the  tear.  You  cannot  expect  with 
a  stitch  put  in  like  this  so  to  close  the  rent 
as  to  make  it  heal,  but  the  pressure  of  a  stitch  will 
stop  bleeding.  It  has  been  recommended  to  expose 
the  part  with  a  speculum,  and  thus  sew  it  up.  These 
cases  are  so  rare  that  I  cannot  from  experience  say 
which  method  is  the  better,  supposing  that  speculum, 
assistants,  lights,  etc.,  are  all  ready.  But  you  ought 
to  have  needles,  thread,  and  holders  with  you,  in 
readiness  for  possible  rupture  of  the  perineum,  and 
you  will  only  seldom  have  the  tools  for  stitching  with 
the  aid  of  sight.  It  has  been  pi'oposed  to  stitch  up 
tears  that  are  not  big  enough  to  bleed,  under  the  idea 
that  disease  of  the  uterus  might  thus  be  prevented ;  but 
there  is  no  evidence  that  any  disease  is  so  prevented. 

(b)  Inversion  of  the  uterus  means  that  the 

organ  is  turned  inside  out,  so  that  what  is  normally 
its  internal  surface  becomes  external  and  bulges  into 
the  vagina  like  a  tumour ;  while  its  peritoneal  surface 
becomes  a  cavity,  in  which  lie  the  ovaries  and  tubes. 
Sometimes  the  cause  that  produced  inversion  produces 
also  prolapse,  so  that  the  inverted  womb  protrudes 
outside  the  vulva. 

How  produced. — Inversion  may  take  place  be- 
fore, or  during,  or  after  the  detachment  of  the  placenta, 
and  accordingly  the  placenta  may  be  adherent  to  the 
inverted  uterus  or  be  partly  separated,  or  the  uterus 
may  be  free  from  the  placenta.  Inversion  of  the 
uterus  is  produced  in  one  of  two  ways  :  the  body  of 
the  uterus  may  be  (1)  pushed  down  from  above,  or  (2) 
pulled  down  from  below.  For  the  production  of 
inversion  it  is  necessary  that  the  body  of  the  uterus 
should  be  quite  relaxed ;    it  is  not  possible  that  the 


Inversion  of  the    Uterus.  345 

uterus  should  be  inverted  while  it  is  contacted.     The 
internal  os  may  or  may  not  be  contracted. 

(1)  The  body  of  the  uterus  may  be  pushed  down 
either  by  the  patient's  own  bearing-down  efforts 
or  by  the  pressure  of  the  attendant's  hand  on  the 
abdomen.  The  uterus  cannot  remain  long  relaxed 
after  delivery,  for  were  it  to  do  so,  the  patient  would 
soon  die  from  haemorrhage.  Inversion,  therefore,  of 
the  uterus  can  only  occur  immediately  after  the  birth 
of  the  child  or  the  expulsion  of  the  placenta. 

(2)  The  body  of  the  uterus  may  be  pulled  down  by 
the  cord.  The  cord  may  be  too  short  to  allow  birth 
of  the  child  without  change  in  the  situation  of  its 
uterine  attachment,  or  it  may  be  made  short  by  being 
coiled  round  the  child  ;  it  may  be  accidentally  pulled 
upon,  as  when  the  mother  is  delivered  while  standing ; 
or  it  may  be  injudiciously  pulled  upon  to  remove  the 
placenta.  The  uterine  body  may  also  be  dragged 
down  by  a  fibroid  tumour  attached  to  it :  this  latter 
is  the  only  way  in  which  inversion  is  produced  apart 
from  pregnancy. 

The  late  Dr.  Matthews  Duncan  divided  inversion 
of  the  uterus  into  active  and  passive,  according  to 
whether  the  lower  part  of  the  uterus  was  contracted 
or  not.  The  force  which  began  the  inversion  may 
complete  it,  without  help  from  the  lower  segment  or 
cervix — this  is  passive  inversion ;  or  the  relaxed  upper 
part  of  the  uterus  may  be  pushed  or  pulled  down 
through  the  lower  parts  of  the  uterus,  and  then  this 
lower  part  may  contract  round  it  and  force  it  farther 
on — this  is  active  inversion.  If  inversion  of  the 
uterus  produced  by  one  of  the  above  causes  has  only 
taken  place  to  a  slight  extent,  forming  a  dimpling-in 
of  the  fundus,  and  then  the  uterus  contracts,  the  con- 
traction will  restore  the  uterus  to  its  proper  shape 
and  undo  the  partial  inversion  (Fig.  126).  We  do 
not  know  where  to  draw  the  line  between  the  slight 
degree  of  inversion  that  is  replaced  when  the  uterus 
contracts  and  the  degree  which  is  forced  farther  on 
bv  uterine  contraction.     If  inversion  has  been  begun 


346 


Difficult  Labour. 


by  some  other  cause,  and  the  patient  strains  or 
vomits,  such  efforts  will  increase  the  inversion  and 
favour  its  combination  with  prolapse. 

Symptoms. — These  are  those  of  haemorrhage 
plus  collapse.  The  collapse  comes  on  suddenly  with 
the  inversion,  so  that  it  is  not  wholly  produced  by 

loss  of  blood.  The 
patient  is  pale,  with 
an  anxious  expression 
of  face,  a  very  small 
and  quick  pulse,  sigh- 
ing breathing,  and 
restlessness.  With 
these  symptoms  there 
is  haemorrhage  from  the 
vagina.  German  writ- 
ers attribute  the  col- 
lapse to  the  reduction 
of  pressure  within  the 
abdomen.  If  this  were 
enough,  we  ought  to 
have  collapse  when- 
ever a  case  of  ascites 
is  tapped  or  a  large 
ovarian  tumour  re- 
moved. I  think  it 
due  to  the  strangnla- 
lation  of  the  uterus 
and  the  sudden  ex- 
exposure  to  friction  of  so  large  a  sensitive  surface  as 
the  interior  of  the  uterus. 

Diagnosis. —  The  diagnosis  of  acute  inversion  of 
the  uterus  ought  to  be  easy.  A  mistake  can  only  be 
made  by  a  person,  very  ignorant  or  so  frightened  as  to 
lose  self-possession.  If  the  tumour  is  seen  outside, 
with  the  placenta  attached  to  it,  its  nature  is  evident 
at  a  glance.  If  it  is  inside  the  vagina,  and  the 
placenta  is  felt  attached  to  it,  inversion  is  the  only 
possibility.  In  the  cases  in  which  harm  has  been 
done  from  a  wrong  diagnosis,  the  inverted  uterus  has 


Fig  126.—  Commencing  Inversion  of 
Uterus.  (From  a  Specimen  in, 
the  Museum  of  Guy's  Hospital.) 


Inversion  of  the    Uterus.  347 

been  taken  either  for  the  head  of  a  second  child  or  for 
a  tumour.  The  first  mistake  ought  not  to  be  made, 
for  nothing  like  sutures  and  fontanelles  exists  in  an 
inverted  uterus.  The  second  error  is  the  only  one 
that  is  pardonable,  and  this  ought  to  be  avoided  by 
feeling  for  the  uterus  through  the  abdominal  wall. 
If  the  vaginal  swelling  be  a  tumour,  the  uterus  will 
be  felt  above  it  when  the  belly  is  kneaded.  If,  on  the 
other  hand,  it  be  inversion,  when  the  hand  is  pressed 
down  on  the  belly  where  the  uterus  ought  to  be,  no 
uterus  will  be  felt;  but  the  top  of  the  tumour  will 
feel  like  a  ring  into  which  the  tips  of  the  fingers  may 
be  pressed.  The  uterus  may  be  inverted  by  a  tumour. 
Puerperal  inversion  is  rare,  and  puerperal  inversion 
by  a  tumour  still  rarer. 

Prognosis. — About  two-thirds  of  cases  of  uterine 
inversion  die  within  the  first  few  hours.  Some  die 
almost  immediately  from  haemorrhage  and  shock ; 
others,  when  bleeding  is  not  great,  gradually  sink  in 
a  few  hours  from  shock.  If  this  clanger  is  conquered, 
the  uterus  may  become  inflamed  or  gangrenous. 
The  patient  may  die  from  haemorrhage  at  any  time 
during  the  lying-in.  If  the  patient  escape  these 
risks,  involution  of  the  uterus  goes  on,  and  acute 
inversion  passes  into  chronic.  The  consideration  of 
chronic  inversion  of  the  uterus  is  beyond  the  scope 
of  this  work. 

Treatment. — The  prophylactic  treatment  of  in- 
version of  the  uterus  consists  in  not  dragging  out 
the  child  or  placenta  in  the  absence  of  pains ;  in 
watchfulness  to  see  that  the  cord  is  not,  by  reason 
of  either  shortness  or  coiling  round  the  child,  made 
tense  and  dragged  down  during  the  birth  of  the 
child  ;  and  in  taking  care  that  good  uterine  retrac- 
tion and  contraction  are  maintained  after  the  birth 
of  the  child. 

When  inversion  has  occurred,  the  treatment  is  to 
push  back  the  inversion.  However  exhausted  the 
patient  may  be,  and  however  unfit  she  may  seem  to 
undergo  an  attempt  at  replacement,  you  must  remem- 


348  Difficult  Labour. 

ber  that  this  is  the  only  thing  that  will  benefit  her, 
and  that  the  longer  you  wait  the  more  difficult  reposi- 
tion will  be,  and  the  less  fit  will  the  patient  be  to 
endure  it.  Therefore,  do  not  waste  time  in  trying  to 
revive  the  patient's  strength,  but  replace  the  uterus 
at  once.  If  the  placenta  is  still  attached  to  the  uterus 
it  matters  little  whether  you  detach  it  or  not.  If 
you  can  peel  it  off  quickly,  do  so  ;  if  not,  reduce  the 
inversion  with  the  placenta  attached.  If  the  uterus 
is  still  relaxed,  reposition  is  easy.  Press  the  closed 
fist  against  the  fundus  and  push  it  up  ;  or  take  the 
uterus  in  the  palm  of  the  hand,  compress  it  so  as  to 
make  it  as  small  as  possible,  and  press  it  up  in  the 
axis  of  the  pelvic  inlet.  Steady  pressure  in  the  right 
direction  is  required,  rather  than  great  force.  At 
the  same  time  place  the  other  hand  on  the  abdo- 
men, and  press  the  tips  of  the  fingers,  placed 
together  in  the  form  of  a  cone,  into  the  cervix  so 
as  to  dilate  it,  for  the  contracted  os  internum  is  the 
obstacle  which  opposes  reduction.  An  anaesthetic  will 
make  reposition  easier,  but  rather  than  delay  re- 
place the  uterus  without  anaesthesia.  If  the  uterus 
be  contracted,  reposition  will  be  difficult ;  hence  the 
need  for  haste. 


c.  Disease  of  Blood  or  Blood- Vessels. 

There  are  certain  diseases  which  render  the  patient 
more  liable  to  bleed.  These  are  chronic  Bright's  dis- 
ease, scurvy,  purpura,  phosphorus  poisoning,  acute 
atrophy  of  liver,  haemophilia.  The  acute  renal  disease 
which  produces  eclampsia  is  not  usually  attended  with 
vascular  degeneration,  and  therefore  has  no  marked 
tendency  to  cause  haemorrhage.  These  diseases  are 
rare  in  pregnant  women,  for  women  suffering  from 
them  seldom  become  pregnant,  and  if  they  do,  often 
abort  early.  The  treatment  of  post-partum  haemorrhage 
from  these  causes  is  the  same  as  that  of  haemorrhage 
from  uterine  atony. 


Collapse  after   Hemorrhage.         349 

Treatment  of  Collapse  after  Hemorrhage. 

In  post-partum  haemorrhage  the  first  thing  is  to 
stop  the  bleeding.  All  other  treatment,  such  as 
raising  the  foot  of  the  bed,  bandaging  the  legs,  inject- 
ing ether  or  brandy,  etc.,  is  mere  trifling  in  com- 
parison with  stopping  the  bleeding. 

Suppose,  now,  that  you  have  got  this  done.  The 
uterus  remains  retracted,  with  contractions  recurring 
at  intervals.  Be  certain  that  this  state  is  permanent 
before  you  discontinue  attention  to  the  uterus.  Do 
not  leave  the  patient,  but  examine  the  womb  through 
the  belly-wall  every  five  minutes  tor  at  least  an  hour 
after  the  bleeding  seems  to  have  stopped. 

If  the  bleeding  has  stopped,  the  patient  is  not 
therefore  out  of  danger.  If  very  much  blood  has  been 
lost,  so  that  the  patient  is  greatly  weakened,  she  may 
slowly  get  weaker  and  weaker,  and  die  from  exhaustion 
some  hours  after  the  cessation  of  the  bleeding.  The 
pulse  gets  smaller  and  smaller,  the  extremities  become 
cold,  the  breathing  begins  to  be  hurried,  and  the 
patient  becomes  restless.  This  may  happen  in  spite 
of  the  utmost  attention  in  plying  the  patient  with 
liquid  food  and  stimulants. 

When  a  patient  dies  from  bleeding,  death  takes 
place  from  reduction  of  the  amount  of  blood,  not  from 
loss  of  blood  corpuscles.  A  previously  healthy  patient 
dying  from  haemorrhage  has  more  blood  corpuscles 
than  one  who  is  walking  about  in  a  state  of  great 
anaemia.  Therefore,  to  prevent  death  from  bleeding 
which  has  already  taken  place,  what  we  have  to  do  is 
to  put  more  fluid  in  the  blood-vessels. 

The  transfusion  Of  blood  is  a  very  old  remedy. 
It  is  dangerous  and  ineffective.  It  is  dangerous, 
because  blood  drawn  from  the  veins  clots,  and  the 
introduction  of  clot  into  the  circulation  may  kill. 
Different  plans  have  been  devised  for  avoiding  the 
dangers  of  transfusing  blood,  but  none  of  them  is 
satisfactory.  Instruments  have  been  invented  for 
transiusing  blood  directly  from  the  vein  of  the  giver 


35°  Difficult  Labour. 

to  that  of  the  receiver,  so  that  the  blood  may  get  into 
the  receiver's  circulation  before  it  has  time  to  clot. 
But  there  is  no  instrument  that  msets  the  require- 
ments of  practice;  they  are  all  either  difficult  to  work 
or  uncertain  in  their  action.  No  mode  of  transfusion 
is  useful  that  is  not  easy,  for  the  operation  has  to  be 
done  in  a  hurry,  and  it  is  so  seldom  called  for  that 
few  have  the  opportunity  of  gaining  dexterity  by 
practice.  Blood  has  been  defibrinated  by  whipping. 
This  takes  a  long  time,  and  you  want  the  remedy 
quickly.  If  the  defibrination  is  not  perfect,  the 
operation  is  dangerous.  The  blood  has  been  prevented 
from  clotting  by  mixing  it  with  phosphate  of  soda. 
But  the  clotting  of  blood  is  a  vital  action,  and  one 
would  expect  that  an  agent  which  will  prevent  the 
blood  from  clotting  out  of  the  body  would  interfere 
with  the  life  of  the  blood  in  the  body  into  which  the 
phosphate  of  soda  is  injected.  As  a  matter  of  fact,  all 
the  reported  cases  in  which  this  solution  has  been 
used  have  ended  fatally. 

The  transfusion  of  blood  is  ineffective^  because  you 
cannot  prudently  take  from  the  giver  as  much  blood 
as  is  necessary  to  revive  a  patient  sinking  from  the 
effects  of  a  great  haemorrhage. 

Intravenous   saline   injection.  —  The    safest 

way  to  sustain  the  circulation  of  such  a  patient  is  to 
inject  saline  fluid  into  the  veins.  Water  may  be 
injected  without  doing  injury,  but  it  seems  more 
physiological  to  inject  a  fluid  of  nearly  the  specific 
gravity  of  blood  serum.  Common  salt  may  be  had  in 
any  house.  If  you  can  get  six  pints  of  water  that 
has  been  boiled,  you  may  be  sure  that  it  will  not 
contain  any  microbes.  If  you  cannot  get  so  much 
boiled  water  as  this,  reflect  that  the  chances  against 
ordinary  tap-water  containing  disease  germs  are  as 
millions  to  one,  and  use  water  from  the  tap.  Get  it 
as  nearly  the  temperature  of  the  body  as  possible ;  but 
if  a  few  degrees  below  that  temperature,  no  harm  will 
result.  Dissolve  common  salt  in  the  water,  a  tea- 
spoonful  in  each  pint. 


Intravenous  Saline  Injection. 


35* 


Cut  through  the  skin  over  the  median  cephalic  vein, 
and  expose  the  vein.  Put  a  couple  of  probes  under- 
neath it,  and  move  one  upwards,  the  other  downwards, 
so  as  to  isolate  a  little  strip  of  vein  between  them. 


Fig.  127. — Intravenous  Saline  Injection.     (After  Horrocks.) 


Fill  the  funnel  or  syringe  with  the  fluid.  Let  a  little 
run  out,  so  that  you  may  be  sure  the  nozzle  does  not 
contain  air.  Open  the  vein  and  insert  the  nozzle. 
Let  a  little  fluid  run,  as  a  further  precaution  against 
the  admission  of  air,  and  then  remove  the  upper  probe, 
and  the  fluid  will  flow  on  into  the  circulation  (Fig. 
127).     A  funnel  may  be  used.     The  syringe  recom- 


352  Difficult  Labour. 

mended  by  Braxton  Hicks  can  be  used  either  as  a 
funnel  or  a  syringe.  The  intravenous  injection  case 
should  contain  a  funnel  or  syringe,  piece  of  indiarubber 
tubing  about  18  inches  long,  two  nozzles  for  intra- 
venous use,  dissecting  forceps,  two  double-edged  fine 
knives  in  handles,  four  probes,  Gamgee  tissue,  and  a 
foot  of  strapping  at  least  an  inch  wide. 

Injection  into  Cellular  tissue. — Intravenous 
injection  of  saline  fluid  is  the  quickest  way  of 
reviving  a  patient  dying  from  loss  of  blood.  An 
easier  way,  if  the  patient  is  not  in  extremis,  is  to 
inject  fluid  into  the  cellular  tissue  under  the  breasts. 
Barnard's  is  the  best  way  of  doing  it.  An  indiarubber 
tube,  weighted  at  one  end,  at  the  other  carries  the 
fluid  to  a  glass  T  piece.  This  is  connected  by  two 
further  lengths  of  rubber  tubing  to  two  brandy- 
syringe  needles.  About  a  gallon  of  saline  solution 
in  boiled  water  should  be  prepared  and  put  in  a 
large  jug  which  has  been  scalded  out.  This  should 
be  placed  about  a  foot  higher  than  the  level  of 
the  patient's  body :  if  higher  than  this,  pain  will  be 
caused.  The  whole  apparatus  should  have  been 
boiled,  and  the  skin  at  the  site  of  injection  made 
as  aseptic  as  possible.  A  syphon  action  is  estab- 
lished by  putting  the  whole  apparatus  in  the  fluid, 
and  then  clipping  the  ends  close  to  the  needles. 
Then  the  needles  are  inserted ;  one  beneath  each 
breast.  About  a  pint  will  flow  through  each 
needle   per   hour. 


353 


CHAPTER    XX  V. 

THE   FORCEPS. 


The  forceps  may  be  described  as  an  artificial  hand, 
the  use  of  which  is  to  grasp  the  foetal  head  and  pull  it 
through  the  pelvis  when  the  natural  forces  are  unable 
to  push  it  through. 

Consider  first  when  to  use  the  forceps,  and  then 
hovj  to  use  it. 

Indications  for  forceps. — The  great  indication 
for  forceps  is  that  the  pains  are  not  strong  enough  to 
effect  delivery  within  the  ordinary  limit  of  time.  The 
reason  of  this  may  be  either  (1)  "primary  uterine 
inertia,"  everything  else  being  normal ;  or  (2)  that, 
although  the  pains  are  as  strong  as  usual,  there  is 
obstruction,  with  relative  weakness  of  pains.  The 
obstruction  may  be  either  due  to  the  bones  or  the  soft 
parts.  Obstruction  due  to  the  bones  may  be  either 
because  the  pelvis  is  too  small  or  the  child's  head  too 
large.  In  either  form  of  lingering  labour  it  may  be 
the  best  practice  to  help  delivery  by  pulling. 

The  forceps  is  intended  to  seize  the  head.  It  is, 
therefore,  only  to  be  used  in  head  presentations. 

Membranes  should  be  ruptured. — The  forceps 

is  never  required  while  the  bag  of  waters  is  entire,  for 
the  reasons  which  follow  : — (In  some  few  cases  the 
liquor  amnii  is  abnormally  deficient.  It  is  impossible 
to  distinguish  such  cases  from  those  in  which  the 
liquor  amnii  has  escaped  early,  and  therefore  for 
practical  purposes  such  cases  may  be  regarded  as  cases 
in  which  the  membranes  have  ruptured).  1.  The 
forceps  is  not  l-equired  while  the  bag  of  waters  is 
entire  and  the  os  is  not  fully  dilated,  because  the  bag 
of  waters  will  dilate  the  cervix  far  better  than  the 
forceps,  and  no  danger  can  come  to  mother  or  child 
from  delay  so  long  as  the  bag  of  waters  is  entire, 
x— 36 


354  Difficult  Labour. 

2.  If  the  os  is  fully  dilated  and  the  memhranes  not 
ruptured,  the  proper  course  is  to  rupture  them.  If 
labour  should  before  have  seemed  lingering,  the 
rupture  of  the  membranes  will  often  provoke  more 
vigorous  action  of  the  uterus. 

When  possibly  required. — When  the  head  is 
presenting  and  the  membranes  have  ruptured,  there 
are  three  conditions  in  which  we  may  have  to  consider 
whether  forceps  ought  to  be  used. 

1.  The  os  uteri  is  not  fully  dilated  and  the  head  is 
above  the  brim. 

2.  The  os  uteri  is  fully  dilated  and  the  head  is 
above  the  brim. 

3.  The  head  has  descended  into  the  pelvic  cavity. 
Cases  of  the  first  and  second  kinds  are  rare.    Cases 

of  the  third  kind  are  very  common,  and  form  the  vast 
majority  of  those  in  which  the  instrument  is  used. 
Consider  these  three  conditions  more  fully. 

1.  Before  full  dilatation  of  cervix. — The  for- 
ceps is  sometimes,  but  very  seldom,  needed  before  the 
os  uteri  is  fully  dilated,  but  never  unless  the  head  is  so 
detained  above  the  brim  of  the  pelvis  that  it  cannot 
come  down  into  the  os  to  dilate  it.  With  a  well- 
shaped  pelvis  and  a  child  of  average  size  the  head 
sinks  well  down  into  the  lower  segment  of  the  uterus 
before  labour  begins,  and  remains  there  while  the  os  is 
dilating.  With  a  normal  pelvis  and  foetal  head  there 
can  be  no  reason  for  applying  forceps  before  dilatation 
of  the  os  to  four-fifths  of  its  full  size. 

If  the  pelvis  is  flattened,  the  head  during  the  first 
stage  may  remain  above  the  brim,  pressed  down  upon 
it  during  the  pains,  but  movable  above  it  while  the 
uterus  is  relaxed.  Pressm-e  upon  the  uterine  wall 
will  never  be  continuous  while  the  os  uteri  is  small, 
for  tonic  contraction  of  the  uterus  never  comes  on  in 
the  early  part  of  the  first  stage  of  labour.  There  is 
therefore  no  reason  for  applying  forceps  with  the  head 
above  the  brim  at  this  time.  Special  forceps  have 
been  constructed  for  application  through  a  small  os 
uteri.     Experience  has  shown  that  this  is  very  bad 


Forceps  above  the  Brim.  355 

practice.*  If  the  head  can  come  down  into  the  os,  it 
will  dilate  it ;  and  if  the  dilatation  is  slow,  the  remedy 
is  to  support  the  patient's  strength  while  the  os  is 
being  opened  up  by  giving  her  food  and  promoting 
sleep,  not  to  tear  the  os  open  by  dragging  the  head 
rapidly  through  it. 

It  may  therefore  be  laid  down  as  a  rule  that  the 
forceps  is  never  required  while  the  os  uteri  is  so  small 
as  not  to  admit  four  fingers  ;  and  if  the  head  can  come 
into  the  os  and  stretch  it,  the  forceps  is  not  required 
until  the  os  has  been  fully  dilated. 

Head  above  the  brim;   os  dilatable.— The 

only  cases  in  which  the  forceps  .can  be  required  before 
full  dilatation  of  the  os  are  cases  of  contracted  pelvis 
in  which  the  head  is  presenting  in  a  favourable 
position,  the  membranes  have  ruptured  early  and  the 
uterus  is  acting  powerfully,  forcing  down  the  head 
upon  the  cervix,  and  compressing  it  against  the  brim 
of  the  pelvis  so  as  to  hold  it  down.  If  this  happens, 
the  consequences  of  pressure  that  have  been  described 
in  chapter  xm.  may  follow  if  aid  be  not  given. 
Such  consequences  only  happen  when  the  uterus  has 
been  acting,  for  a  long  time,  never  while  the  os  uteri 
is  small.  And  delivery  by  forceps  is  the  proper 
treatment  in  only  a  few  of  such  cases.  If  the  reason 
why  the  os  does  not  dilate  is  simply  that  the  head 
cannot  come  into  it  to  stretch  it  open,  then  when 
the  head  is  pulled  through  the  brim  with  forceps  the 
os  will  quickly  stretch  open.  In  such  cases  you  find, 
after  the  membranes  have  ruptured,  the  cervix  hanging 
down  below  the  head  like  a  thick  fringe,  but  soft,  and 
admitting  three  or  four  fingers  easily.  The  question 
for  decision  here  is  whether  there  is  only  (a)  contrac- 
tion of  such  a  minor  degree  that  the  head  will  come 
through  by  pulling,  or  (b)  great  disproportion,  so 
that  it  cannot.     If  the  latter,  it  is  bad  practice  to 

*  It  was  carried  out  on  a  large  scale  at  the  Rotunda  Hospital, 
Dublin,  under  the  mastership  of  Dr.  George  Johnston,  with  the 
result  of  doubling  the  maternal  mortality.  (See  Roper,  Obat. 
Trans.,  vol.  xxi.) 


356  Difficult  Labour. 

waste  time  and  run  risk  of  serious  injury  by  trying 
to  deliver  with  forceps.  In  well-marked  cases  the 
decision  is  not  difficult  ;  but  as  we  cannot  ascertain 
with  mathematical  certainty  the  factors  upon  the 
combination  of  which  the  answer  depends,  there  will 
in  the  present  state  of  our  knowledge  always  be  some 
cases  in  which  an  exact  diagnosis  is  impossible.  Re- 
member that  with  a  flat  pelvis  the  position  of  the 
head  most  favourable  for  forceps  delivery  is  when  the 
sagittal  suture  is  running  transversely,  and  distant 
about  an  inch  from  the  sacral  promontory.  (See 
page  204.)  We  can  measure  within  a  quarter  of  an 
inch  the  conjugate  diameter  of  the  brim.  We'  can 
form  a  rough  idea,  by  examining  the  abdomen, 
whether  the  child  is  large  or  small,  or  of  medium  size. 
But  we  have  no  way  of  determining  the  degree  of 
ossification  of  the  bones  of  the  skull,  upon  which 
depends  the  extent  to  which  the  head  can  be  com- 
pressed during  its  passage  through  the  brim. 

Size  of  flat  pelvis  usually  admitting  forceps 

delivery.  —  The  average  size  of  the  bi-parietal 
diameter  of  the  head  is  about  three  inches  and  three- 
quarters.  That  of  a  transverse  diameter  of  the  foetal 
head  taken  about  half  an  inch  in  front  of  the  parietal 
eminences  (which  is  the  diameter  that  lies  in  the 
conjugate  when  the  long  diameter  of  the  head  is  in  the 
transverse  diameter  of  the  brim)  is  about  three  inches 
and  a  half.  The  sub-parietal  super-parietal  diameter, 
which  in  the  most  favourable  situation  (see  page  204) 
is  substituted  for  the  bi-parietal,  is  about  three  inches 
and  a  half.  By  compression  these  diameters  can  be 
further  diminished.  On  the  average,  a  diminution  of 
about  a  quarter  of  an  inch  is  about  the  utmost  which 
is  both  practicable  and  consistent  with  safety.  Hence 
a  conjugate  of  about  three  inches  and  a  quarter  is  the 
smallest  that  will  as  a  rule  allow  forceps  delivery  of  a 
child  at  term.  If  the  head  be  very  hard,  from  the 
ossification  being  more  advanced  than  usual,  it  may 
not  be  possible  to  compress  it  as  much  as  this ;  if 
soft,  from  imperfect  ossification,  it  may  be  compressed 


Head  in  Pelvic  Cavity. 


357 


more  than  this.  But  great  compression  brings  with  it 
risk  of  death  of  the  child  from  meningeal  haemorrhage. 

2.  The  head  is  above  the  brim,  but  the  os 

Uteri  is  fully  dilated. — In  such  a  case  as  this  the 
disproportion  is  probably  slight,  for  the  full  dilatation 
of  the  os  generally  implies  that  the  head  has  been  able 
to  come  down  far  enough  into  it  to  stretch  it  open. 
Try  to  ascertain  how  high  the  greatest  diameter  of 
the  head  is  above  the  brim,  and  if  it  be  only  a  little 
above  the  brim  its  delay  in  entry  is  probably  only 
from  weakness  of  pains,  and  it  will  be  possible  to  pull 
the  head  through  with  forceps. 

3.  Head  in  pelvic  cavity ;  primary  inertia. 

— The  most  common  indication  for  forceps  is  primary 
uterine  inertia  in  the  second  stage  of  labour.  In  the 
first  stage  of  labour  primary  uterine  inertia  requires 
no  treatment  save  patience.  When  the  os  uteri  has 
reached  four-fifths  of  its  full  size,  rupture  the  mem- 
branes if  they  have  not  already  burst.  This  will 
very  often  provoke  stronger  and  more  frequent  pains, 
(1)  because  the  hard  head  irritates  the  cervix  more 
than  the  soft  bag  of  membranes,  and  so  produces  reflex 
contraction,  and  (2)  because  the  letting  off  some  of 
the  liquor  amnii  diminishes  the  uterine  contents 
and  so  helps  the  uterus  to  retract.  When  this 
is  done  the  dilatation  of  the  os  should  be  finished 
within  an  hour  or  two,  and  the  second  stage  should 
last  in  primiparae  about  two  hours  and  in  multi- 
para about  half  an  hour.  But  if  pains  do  not 
gain  in  strength  and  frequency,  instead  of  the 
labour  being  over  in  three  or  four  hours  it  may 
drag  on  six  or  eight  hours  or  even  longer.  This  long- 
continued  suffering  will  at  least  make  the  mother 
very  tired,  it  may  make  her  exhausted,  and  it  is  possible 
that  it  may  favour  the  occurrence  of  post-partum 
haemorrhage,  although  there  is  no  proof  of  this.  If 
the  case  be  let  alone,  very  likely  secondary  uterine 
inertia  will  come  on,  the  pains  will  get  less  and  less 
frequent  and  cease  ;  then  the  patient  will  sleep  for  an 
hour  or  two,  and  after  she  has  slept  the  pains  will 


358  Difficult  Labour. 

recommence.  But  there  is  no  advantage  in  letting 
the  mother's  suffering  be  prolonged  in  this  way,  and 
if  regular  pains  are  present  no  harm  follows  skilful 
delivery  with  forceps.  In  such  cases,  therefore,  it  is 
desirable,  although  not  absolutely  necessary,  to  deliver 
with  forceps. 

The  following  are  the  characteristic  features  of 
such  cases.  The  head  is  low  down  in  the  pelvic 
cavity ;  it  is  not  impacted ;  it  moves  on  with  each 
pain,  presses  down  on  the  perineum, .  and  opens  out 
the  vulval  orifice ;  and  goes  back  between  the  pains. 
The  pains  are  not  frequent,  and  they  are  weak ;  advance 
and  recession  are  marked,  but  with  each  pain  the  head 
is  pushed  on  only  a  very  little  farther  than  with  the 
preceding  one.  The  mother's  pulse  is  not  accelerated ; 
she  does  not  look  anxious,  and  between  the  pains  she 
is  comfortable. 

Impaction  Of  head. — The  next  most  common 
indication  for  forceps  is  delay  in  the  second  stage 
from  large  size  of  the  foetal  head.  When  the  pelvis 
and  the  head  are  well  shaped  the  dilatation  of  the 
cervix  goes  on  naturally,  because  the  head  comes 
down  into  the  os,  and  so  relieves  the  forewaters  from 
the  general  iutra-uterine  pressure.  When  the  cervix 
is  fully  dilated  the  head  comes  down  into  the  pelvic 
cavity ;  but  being  very  large  and  hard,  it  fills  the 
cavity,  compresses  the  soft  parts  which  lie  between  it 
and  the  pelvic  wall,  and  so  the  friction  is  great. 
Consequently  it  may  become  impacted,  that  is,  stuck 
fast,  neither  advancing  with  the  pains  nor  receding 
in  the  interval.  When  it  has  become  impacted  the 
continuous  pressure  on  the  soft  parts  impedes  the 
circulation  through  them.  Hence  the  parts  below 
become  swollen  from  oedema,  and  the  mucous  mem- 
brane does  not  secrete  properly,  and  therefore  it 
becomes  dry.  The  congestion  also  makes  it  feel  hot, 
and  makes  it  more  tender  than  it  should  be.  If  the 
impaction  is  allowed  to  continue  long  the  parts  pressed 
on  will  slough. 

Therefore     when     impaction     has     taken     place 


Forceps  in  Impaction,  359 

immediate  delivery  is  necessary  ;  and  the  only  question 
is,  whether  the  forceps  shall  be  tried,  or  the  head  per- 
forated. If  the  foetal  heart  is  audible,  the  swelling 
of  the  soft  parts  not  great,  the  most  advanced 
part  of  the  head  low  down,  the  mother's  pulse  not 
very  rapid,  and  her  expression  not  anxious,  if  the 
pains  are  regular,  and  there  are  intervals  between 
them,  try  forceps  delivery.  If,  on  the  other  hand, 
the  uterus  is  in  tonic  contraction,  the  mother's  pulse 
accelerated,  her  expression  anxious,  the  vagina 
and  vulva  are  swollen,  dry,  and  tender,  and  after 
auscultation  of  the  abdomen  when  the  room  is  quiet 
you  cannot  hear  the  fcetal  heart,  do  not  waste  time  or 
incur  risk  of  injury  by  trying  forceps,  but  take  up  the 
perforator  at  once.  A  fruitless  attempt  to  deliver 
with  forceps  implies  an  error  in  diagnosis  on  your  part, 
although,  as  diagnosis  of  the  amount  of  obstruction 
is  not  easy,  the  error  is  not  very  discreditable.  But 
you  ought  not  to  let  labour,  rendered  tedious  by  large 
size  of  the  child's  head,  go  on  till  the  head  is  impacted  ; 
you  should  make  an  early  diagnosis.  If  the  child 
be  large  you  will  find  that  the  abdomen  is  large  ;  its 
measurements  (see  page  195)  will  be  increased  ;  and 
by  feeling  the  abdomen  you  will  find  that  the  enlarge- 
ment is  due  to  the  uterus  and  not  to  dropsy  or  fat  or 
a  tumour  ;  and  that  the  uterine  enlargement  is  due  to 
a  large  child  within  it,  and  not  to  twins  or  a  great 
quantity  of  liquor  amnii.  If  the  pelvis  be  not 
deformed  the  presenting  part  of  the  head  will  have 
sunk  deep  into  it.  You  may  find  that  its  greatest 
diameter  is  a  little  above  the  brim,  but  you  will 
not  find  it  high  above  the  brim.  You  will  also 
notice  that  in  spite  of  strong  and  frequent  pains  the 
head  advances  very  little,  and  it  recedes  also  com- 
paratively little  between  the  pains.  These  points — 
large  size  of  the  child  as  ascertained  by  abdominal 
palpation,  strong  and  frequent  pains,  and  yet  slow 
advance — indicate  that  help  is  needed ;  and  the  fact 
that  the  head  is  either  fully  in  the  pelvic  cavity,  or 
almost  fully,  shows  that  the  mechanical  difficulty  is  not 


360  Difficult  Labour. 

of  such  high  degree  that  forceps  delivery  is  hopeless. 
These  two  conditions,  primary  inertia  and  large  size 
of  the  head,  are  the  indications  for  forceps  when  the 
head  is  in  the  pelvic  cavity,  and  the  pelvis  is  not 
known  to  be  deformed. 

In  labour  with  the  small  round  pelvis  forceps  is 
usually  indicated  unless  the  child  is  small.  The  signs 
marking  the  need  for  forceps  are  the  same  as  those 
detailed  in  the  last  paragraph,  except  that  there  is  no 
indication  that  the  child  is  large. 

Placenta  prsevia. — In  certain  cases  of  placenta 
prcevia — viz.  if  the  placenta  is  only  partially  or  margin- 
ally previa ;  the  os  dilated  to  four-fifths  of  its  full  size ; 
the  pains  pi*esent,  but  feeble ;  the  membranes  rup- 
tured ;  the  head  presenting  with  either  face  or  vertex 
and  coming  down  into  the  os  during  each  pain — 
forceps  should  be  applied. 

You  cannot  apply  forceps  with  the  placenta  com- 
pletely covering  the  os.  If  the  os  is  not  dilated  to  as 
much  as  four-fifths  of  its  full  size,  in  extraction  with 
forceps  it  will  be  stretched  open,  not  by  the  globe  of 
the  head  in  the  grasp  of  the  forceps,  but  by  the  blades 
of  the  forceps  below  the  head,  and  the  forceps  will  be 
likely  to  tear  or  cut  the  cervix,  an  accident  especially 
to  be  avoided  in  placenta  prsevia.  The  half  breech  will 
be  a  better  dilator  than  this.  If  the  pains  are  strong 
there  is  no  need  of  forceps.  If  they  are  absent,  by 
hastily  dragging  out  the  child  you  expose  the  patient 
to  much  risk  of  post-partum  haemorrhage.  If  the 
membranes  are  not  ruptured  by  the  time  the  os  is 
four-fifths  of  its  full  size,  you  ought  to  rupture  them  ; 
possibly  when  this  is  done  tJie  pains  may  become 
strong  enough  to  deliver  the  child  quickly.  If  the 
head  cannot  come  down  into  the  os,  and  is  detained 
above  the  brim,  turning  will  be  better  than  a  prolonged 
attempt  at  forceps  delivery  ;  for  by  turning  we  moro 
quickly  diminish  the  uterine  contents  and  thus  help 
the  uterus  to  contract. 

Prolapse  Of  funis. — Forceps  delivery  is  called 
for  in  some  cases  of  prolapse  0/  the  funis,  viz.  those  in 


Description  of  the  Forceps. 


361 


which  in  a  multipara,  the  os  is  fully  dilated,  the  head 
well  engaged  in  the  brim,  while  down  by  its  side  there  is 
a  loop  of  cord  which  cannot  be  got  to  stay  in  the  uterus. 
In  such  a  case,  rapid  delivery,  so  that  tbe  cord  may  be 
pressed  on  for  only  a 
short  time,  gives  the 
best  chance  for  the 
child,  and  is  not  likely 
to  harm  the  mother 
If  the  head  is  not  en- 
gaged in  the  brim,  the 
os  not  fully  dilated,  the 
soft  parts  of  the  pelvic 
floor  as  firm  as  they 
usually  are  in  primi- 
parse,  you  will  not  be 
able  to  deliver  quickly 
enough  to  save  the 
child  without  the  risk 
of  serious  lacerations 
of  the  maternal  parts ; 
here,  therefore,  turning 
is  better. 

The     instrument 

(Fig.  128)  consists  of 
two  halves  introduced 
separately  and  after- 
wards locked.  Each 
half  consists  of  four 
parts  :  the  blade  to 
grasp     the 


shank,  the 
the  handle, 
of   steel, 


head,  the 
lock,  and 
The  blade 

but  should 


Fig.  ]?,8.— Dauber's  Forceps. 


be  nickel-plated  to  prevent  it  from  rusting.  The  blades 
will  yield  a  little  when  they  are  pressed  apart.  Each 
is  curved  on  the  flat,  to  hold  the  head.  This  curve 
should  be  part  of  a  circle  having  a  radius  of  four 
inches  and  a  half,  and  is  called  the  head  curve.  The 
blade  is  also  curved  in  the  plane  of  its  edge,  to  adapt 


362  Difficult  Labour. 

it  to  the  axis  of  the  pelvis.  This  is  called  .the  pelvic 
curve ;  the  amount  of  curvature  is  the  same  as  that  of 
the  head  curve.  The  surface  is  smooth,  and  the  edges 
are  rounded.  Each  blade  is  open  in  the  middle,  so  that 
it  may  take  up  less  room.  The  distance  between  the 
blades  at  their  widest  part  outside  is  usually  3§  in.  ; 
between  the  tips  \\  in.  When  applied  to  the  head 
the  distance  is  greater,  because  the  blades  yield.  The 
tips  should  not  come  nearer  together  than  this,  for  if 
they  do  it  is  possible  the  child  may  be  injured  when 
they  are  pressed  together.  The  shank  is  the  part 
between  the  blade  and  the  lock.  Its  purpose  is  to 
lengthen  the  instrument,  so  that  when  it  grasps  the 
head  at  the  brim  the  lock  may  be  outside  the  vulva. 
The  part  nearest  the  lock  is  bulged  out  so  as  to  leave 
room  for  a  finger  for  convenience  of  pulling.  If 
the  shank  is  made  concave  behind,  you  can  pull  in 
the  axis  of  the  pelvic  brim  without  pressing  on  the 
perineum  so  much  as  when  the  shank  is  straight. 

The  English  lock  (which  is  the  best)  consists  of  a 
shoulder  with  a  groove,  where  the  handle  joins  the 
shank ;  in  the  groove  the  shank  of  the  opposite  blade 
lies.  Continental  forceps  are  joined  by  a  stud  on  one 
blade  which  enters  a  slot  in  the  other.  The  English 
instrument-makers  so  place  the  grooves  that  the  shank 
of  the  right  blade  lies  in  front  of  that  of  the  left  one. 
Hence  the  left  half  of  the  instrument,  which  in  the 
ordinary  position  is  the  lower,  must  be  put  on  first. 
If  the  upper  blade  is  put  on  first,  the  lower  must  be 
passed  between  it  and  the  perineum. 

The  handles  are  best  made  of  metal,  so  that  the  in- 
strument can  be  boiled  if  necessary.  They  should  have 
a  projecting  shoulder  on  which  the  fingers  can  pull. 
Their  sides  are  generally  made  undulating  that  a  better 
grasp  maybe  got.  There  should  be  no  roughening  by 
cutting  of  fine  lines  ;  for  such  fine  hues  hold  dirt,  and 
are  hard  to  clean.  The  length  of  the  whole  instrument 
is  about  fifteen  inches.  Dr.  Dauber  has  designed  a 
forceps  having  the  character  described  (Fig.  128). 

Short  forceps   without  pelvic   curve  were  at  one 


The   Pendulum  Movement.  363 

time  used.  But  they  can  only  grasp  the  head  when 
it  is  in  the  pelvic  cavity,  not  when  it  is  at  the  brim. 
The  long  forceps  can  be  used  just  as  well  in  the 
cavity  as  at  the  brim.  Therefore  there  is  no  need 
to  load  the  bag  with  both  instruments. 

Action  Of  forceps.— You  can  do  two  things  with 
the  forceps:  (1)  pull;  and  (2)  compress  the  head.  Of 
these,  pulling  is  the  chief.  You  may  pull  in  two 
ways  :  (1)  a  straight  pull ;  (2)  pulling  so  that  you 
make  the  head  with  the  forceps  into  a  lever.  This  is 
done  by  swaying  the  handles  from  side  to  side,  and  is 
called  the  "  pendulum  movement." 

Pendulum  movement. — The  effect  of  this  move- 
ment is  twofold  :  (a)  to  overcome  the  resistance  clue 
to  friction,  (b)  to  change  the  position  of  the  head. 

(a)  To  overcome  f  Actional  resistance.  When  with 
the  forceps  the  head  is  swayed  from  side  to  side,  the 
head  is  pressed  more  strongly  against  the  wall  of 
the  pelvis  on  the  side  towards  which  the  handles  of 
the  forceps  are  swung  than  on  the  opposite  side. 
Hence  on  that  side  the  friction  is  greater.  The  head 
is  converted  into  a  lever,  the  side  pressed  against  the 
pelvic  wall  being  the  fulcrum,  the  weight  the  resist- 
ance to  the  advance  of  the  head. 

Galabin  has  shown  that  one  of  four  results  may 
follow  from  the  pendulum  movement. 

1.  The  side  of  the  head  most  pressed  against  the 
pelvic  wall  may  be  fixed.  In  that  case  the  other  side 
will  move  on. 

The  head  with  the  forceps  forms  a  lever.  The 
fulcrum  is  at  the  pelvic  wall  against  which  the  fixed 
side  of  the  head  presses.  The  resistance  acts  along 
the  pelvic  axis,  not  far  from  the  centre  of  the  head. 
(The  exact  place  depends  upon  the  size  of  the  pelvis 
and  the  ease  with  which  the  soft  parts  can  be  dilated. 
If  the  resistance  is  mainly  from  the  bones,  it  will  act 
at  the  point  where  the  head  is  in  contact  with  the 
opposite  pelvic  wall.  If  from  the  soft  parts,  it  will 
act  near  the  centre  of  the  head.)  The  power  acts  at 
the  point  where  the  handles  are  grasped.     Only  that 


364  Difficult  Labour. 

part  of  it  which  rotates  the  head  about  the  fulcrum 
exerts  a  leverage  action.  The  mechanical  advantage 
of  the  lever  is  measured  by  the  ratio  of  (a)  the 
distance  between  the  place  where  the  handles  are 
grasped  and  the  fulcrum  to  (ft)  the  distance  between 
the  point  at  which  the  resistance  acts  and  the  fulcrum. 
With  ordinary  long  forceps  the  former  (a)  will  be 
about  eleven  inches,  the  latter  (ft)  (taking  the  resist- 
ance to  act  on  the  centre  of  the  head)  about  two  inches. 

2.  The  side  of  the  head  pressed  against  the  pelvic 
wall  may  slip  back  somewhat,  but  not  so  much  as  the 
opposite  side  advances.  In  this  case  (supposing  the 
resistance  to  be  as  before)  the  fulcrum  is  an  axis  inter- 
mediate between  the  centre  of  the  head  and  the  side 
which  is  pressed  against  the  pelvic  wall.  When 
traction  combined  with  the  oscillatory  movement  is 
made,  the  friction  over  the  part  of  the  head  which 
slips  back  is  reversed  in  direction,  since  it  is  made  to 
resist  a  slipping  back  instead  of  an  advance.  Hence 
the  force  needed  to  make  the  head  move  on  is  less 
than  that  which  would  be  wanted  with  direct  pulling  by 
twice  the  amount  of  friction  which  is  so  reversed ;  for 
the  reversed  friction,  instead  of  opposing  the  onward 
pull,  assists  it,  by  neutralising  an  equal  amount  of 
friction  at  the  other  side  of  the  hea*d. 

3.  One  side  of  the  head  may  slip  back  as  much  as 
the  other  side  descends.  In  this  case  there  is  no  lever- 
age tending  to  aid  extraction,  no  advance  of  the  centre 
of  the  head,  and  the  pendulum  movement  is  useless. 

Dr.  Galabin,  in  the  able  paper  from  which  the 
above  is  taken,  says  (speaking  of  the  case  in  which 
one  side  of  the  head  slips  back  a  little,  while  the  other 
side  moves  on  more),  that  "under  the  most  favourable 
conditions  possible  the  amount  of  friction  reversed 
might  be  nearly  one  half  of  the  whole.  In  this  case 
nearly  the  whole  of  the  resistance  due  to  friction 
might  be  done  away  with  by  the  use  of  the  oscillatory 
movement  of  the  handles."  In  this  statement  fric- 
tion is  only  considered  as  opposing  advance.  But 
friction  not  only  opposes  advance,  it  opposes  rotation ; 


The  Pendulum  Movement,  365 

and  considered  as  opposing  rotation,  the  frictions  at 
opposite  ends  of  the  head  globe  help  one  another 
instead  of  opposing  one  another.  In  case  3  (one 
end  slipping  back  as  much  as  the  other  slips  forwards) 
there  is  not  only  no  gain  from  oscillation,  but  loss, 
for  the  power  which  would  otherwise  have  made 
the  head  move  on  is  expended  in  overcoming  the 
resistance  of  friction  to  rotation.  In  case  2  the 
more  the  head  slips  back  the  greater  is  the  frictional 
resistance  to  rotation.  It  is  difficult  to  say  at  what 
point  the  gain  by  overcoming  frictional  resistance 
to  advance,  is  greater  than  the  loss  by  creating 
frictional  resistance  to  rotation. 

4.  The  remaining  possibility  is  that  the  forceps 
may  slip  on  the  head.  Therefore,  if  the  pendulum 
movement  is  to  be  used,  the  forceps  should  be  held 
tightly ;  for  slipping  of  the  forceps  will  not  only 
make  the  movement  useless  but  bring  with  it  danger 
of  injury  to  the  soft  parts. 

(b)  Advantage  of  the  pendulum  movement  in 
changing  position  of  head.  It  is  not  possible  with 
the  knowledge  that  we  can  get  of  the  size  and  shape 
of  a  particular  pelvis  and  that  of  a  foetal  head,  during 
labour,  to  be  quite  sure  that  the  head  is  lying  not 
only  with  its  smallest  but  with  its  most  compres- 
sible diameter  across  the  smallest  diameter  of  the 
pelvis.  The  diameter  which  is  the  smallest  is  not  of 
necessity  the  most  compressible.  By  the  oscillatory 
movement  we  change  the  position  of  the  head,  and  it  is 
possible  that  such  change  may  bring  a  smaller,  or  a 
more  compressible  diameter,  across  the  pelvis,  and  in 
this  way  make  delivery  easier. 

The  illustration  of  the  straight  pull  used  in  draw- 
ing a  cork  from  a  bottle  with  a  corkscrew  has  been 
brought  as  an  argument  against  the  pendulum  move- 
ment. It  has  been  pointed  out  by  Galabin  that  a 
fo3tal  head  is  not  a  cylinder  like  a  cork.  I  may  add 
further,  that  although  with  a  corkscrew  a  straight 
pull  is  used,  when  one  tries  to  get  a  cork  out  with 
the   fingers  the   pendulum   movement  is  used.     The 


3 66  Difficult  Labour. 

cork  is  pressed  first  one  way,  then  the  other,  and  this 
pressure  compresses  one  side  of  the  cork,  loosens  the 
other,  and  thus  helps  extraction.  In  a  like  way  it  is 
possible  that  the  pendulum  movement  applied  to  the 
foetal  head  may  compress  one  side  of  the  head  and 
loosen  the  other.  We  have  no  means  of  knowing  that 
this  takes  place,  but  it  probably  does.  In  this  way, 
rotation,  although  increasing  friction,  may  yet  aid 
extinction, 

In  these  two  ways  the  pendulum  movement  is 
slightly  advantageous. 

When  pendulum  movement  advantageous  — 

When  the  head  is  arrested  at  the  brim,  as  in  a  flat 
pelvis,  the  cause  of  detention  is  not  friction  but 
narrowness  of  the  passage  at  one  point.  To  get  past 
it  the  head  has  to  undergo  temporary  compression. 
The  leverage  effect  of  the  pendulum  movement  is  not 
advantageous ;  but  its  effect  in  getting  a  more  com- 
pressible part  of  the  head  into  the  brim  may  be.  If 
pains  are  weak,  and  the  cause  of  delay  is  in  the  slow 
opening  up  of  the  soft  parts,  there  is  no  advantage  in 
oscillating  the  head.  The  cases  in  which  the  re- 
sistance is  from  friction  are  those  of  impaction  of  the 
head  in  a  small  round  pelvis,  or  of  a  large  head  in  the 
cavity  of  a  normal  pelvis.  Here  the  rotation  from 
side  to  side  is  as  useful  as  rotation  from  before  back- 
wards; and  it  is  attended  with  less  liability  to  slipping 
of  the  blades  on  the  head.  For  this  reason  I  have 
described  the  effect  of  oscillation  from  side  to  side 
instead  of  that  of  oscillation  from  before  backwards, 
which  is  supposed  to  take  place  in  the  paper  of 
Galabin  above  quoted. 

Compression. — It  is  possible  to  compress  the 
head  with  the  forceps.  It  has  been  recommended  to  tie 
the  handles  of  the  forceps  together,  and  clips  and  screws 
have  been  attached  to  forceps  to  keep  up  compression. 
These  are  bad.  The  head  should  be  delivered  with 
as  little  pressure  on  it  as  possible,  and  that  pressure 
should  be  for  as  short  a  time  as  possible.  There 
is  no  need   for  you    to  squeeze  the    head.     If  with 


Compression  with   Forceps.  367 

forceps  you  pull  it  down,  the  wall  of  the  pelvis  will 
compress  it ;  and  this  squeezing  is  applied  just  where 
it  is  wanted,  and  nowhere  elso. 

Compression  should  be  intermittent,  not  con- 
tinuous. Carried  beyond  a  certain  point  it  is 
dangerous,  leading  to  cerebral  or  meningeal  haemor- 
rhage. It  is  impossible  to  apply  compression  with 
such  accuracy  as  to  be  sure  that  you  are  assisting 
delivery  and  yet  not  putting  the  child's  life  in 
danger.  With  ordinary  forceps  the  degree  of  com- 
pression cannot  be  measured,  and  if  it  could,  we  do 
not  know  what  amount  of  pressure  brings  with  it 
danger  of  haemorrhage.  You  will  therefore  best  avoid 
damage  by  squeezing  the  head  for  as  short  a  time  as 
possible,  and  as  little  as  possible.  The  last  condition 
implies  that,  if  the  squeezing  is  to  be  effective,  it 
must  be  applied  exactly  in  the  right  place.  This  is 
not  always  done  with  the  forceps.  When  applied  in  a 
flat  pelvis,  the  forceps  compresses  the  head  in  a  dia- 
meter in  which  there  is  most  room.  Even  in  a  small 
round  pelvis,  or  in  labour  protracted  by  great  size  of 
the  head,  you  cannot  be  certain  that  the  head  is  being 
squeezed  precisely  in  the  direction  in  which  reduc- 
tion of  its  size  is  wanted.  It  is  sometimes  further 
argued  that  when  the  head  is  compressed  in  one  direc- 
tion, its  diameters  in  others  are  increased.  This  is  so. 
But  it  does  not  follow  that  any  diameter  that  has  to 
enter  a  pelvic  diameter  is  increased.  The  increase  is 
often  in  the  direction  of  elongation  of  the  head,  not 
in  increase  of  the  diameters  which  lie  in  the  pelvic 
planes.  But  in  some  few  cases,  pressure  with  the 
forceps  on  the  diameter  lying  in  the  transverse  dia- 
meter of  the  pelvis  does  lead  to  slight  elongation  of 
the  diameter  lying  in  the  antero  posterior  diameter  of 
the  pelvis ;  and  this  is  a  further  argument  against 
direct  compression  with  the  forceps.  To  get  the 
head  compressed  in  exactly  the  diameter  in  which 
compression  is  needed,  the  right  course  is  to  pull,  and 
let  the  pelvis  do  the  compression.  To  get  the  greatest 
effect   from  pulling,  pull  with   the  pains,  and  cease 


368  Difficult  Labour. 

pulling  (thereby  discontinuing  compression  of  the 
head)  in  the  intervals  of  pain. 

If  these  principles  be  sound,  all  contrivances  for 
tying  or  locking  the  handles  of  the  forceps  together 
are  bad. 

Risk  to  child. — The  great  danger  to  the  child 
from  forceps  delivery  is  meningeal  haemorrhage.* 
There  may  be  haemorrhage  into  the  brain,  but  this 
is  much  rarer  (as  1  to  12)  than  meningeal  haemori'hage. 
The  haemorrhage  is  caused  by  the  driving  in  of  edges 
and  corners  of  bone,  either  by  the  tip  or  edges  ot 
the  forceps,  or  by  the  projection  of  the  promontory. 
The  most  vulnerable  part  is  the  anterior  and  lower 
angle  of  the  parietal  bone.  Haemorrhage  is  rather 
more  common  around  the  base  of  the  brain  than  over 
the  hemispheres.  The  pressure  of  the  forceps  blades 
may  so  compress  the  facial  nerve  or  nerves,  as  to 
sever  their  continuity,  so  that  facial  paralysis  occurs. 
This  may  be  bilateral,!  but  is  oftener  on  one  side 
only.     It  usually  gets  well  within  a  fortnight. 

Application. — 1.  If  the  patient  be  not  anaesthe- 
tised, warm  the  blades,  lest  the  feel  of  the  cold  metal 
be  disagreeable.  If  she  be  unconscious  this  is  un- 
necessary.    2.  Anoint  them  with  sublimate  glycerine. 

The  patient  should  lie  with  her  body  across  the 
Ded,  so  that  the  operator  faces  the  orifice  of  the 
genital  canal.  Seated  nearer  the  patient's  back  than 
this,  you  cannot  easily  pull  in  the  proper  direction. 

Position. — In  Great  Britain  the  patient  usually 
lies  on  her  left  side ;  in  other  countries  on  the  back. 
The  left  sided  posture  has  the  advantage  that  less 
assistance  is  required.  In  the  dorsal  position  there 
must  be  an  assistant  to  hold  each  thigh.  As  the 
forceps  can  be  applied  quite  well  with  the  patient  on 
her  left  side,  there  is  no  advantage  in  making  her 
change  her  position. 

Choice  of  blade. — In  the  forceps  sold  by  English 
makers  the  lock  is  so  made  that  the  right-hand  (i.e. 

*  See  Spencer,  Obst.  Trans.,  vol.  xxxiii. 

i  See  Edgworth,  Brit,  Med.  Journal,  January  6th,  1891. 


Application  of  Forceps. 


369 


in  the  left  lateral  position,  the  upper)  blade  is  in  front 
of  the  other  when  the  instrument  is  locked.  Hence 
if  you  pass  the  upper  blade  first,  you  will  have  to  pass 
the  lower  blade  behind  it,  that  is,  between  it  and  the 
perineum,  which  is  inconvenient.  Therefore  pass  the 
lower  blade  first.  By  lower  blade  is  meant  that  lying 
in  the  lower  or  left  side  of  the  pelvis. 

Introduction. — Take  the   lower  blade  in  your 


Fig.  129.- -Showing  first  Stage  of  Introduction  ot  lower  Blade  of  Forceps  : 
blade  passed  in  antero-posterior  direction,  its  tip  impinging  on  left 
sacro-sciatic  ligament.    (After  R.  Barnes.) 

right  hand.  Pass  up  two  fingers  of  the  left  hand 
until  they  either  feel  the  os,  or  feel  the  head  meeting 
the  vaginal  wall  without  the  intervention  of  the  cervix 
uteri.  It  is  of  the  first  importance  that  either  the  os 
should  be  felt,  or  that  you  should  be  quite  certain  that 
it  is  retracted  above  the  greatest  diameter  of  the 
child's  head.  Carelessness  about  this  point  has  led 
to  perforation  of  the  vagina,  the  bladder,  and  even  the 
abdominal  cavity. 
y— 36 


370 


Difficult  Labour. 


Having  ascertained  beyond  doubt  the  position  of 
the  os  uteri,  keep  the  tips  of  the  fingers  on  the  os, 
or,  if  the  os  be  retracted,  on  the  head  as  near  as 
possible  to  the  line  of  its  contact  with  the  pelvic 
wall,  and  pass  the  blade  along  the  palmar  surface  of 
the  fingers.  Pass  it  so  that  the  line  of  the  handle 
and  shank  is  parallel  with  the  anteroposterior 
diameter  of   the   pelvis   (Fig.    129).      When   passed 


Fig.  130.— Showing  second  Stage  of  Introduction  of  lower  Blade  of 
Forceps  :  point  moving  upwards  and  forwards  around  head  into  left 
side  of  pelvis.    (After  R.  Barnes.) 

up  in  this  way  the  tip  of  the  blade  will  come 
upon  the  left  sacro-sciatic  ligament.  Now,  while  you 
press  the  tip  gently  upwards,  carry  the  handle  in  a 
curve  first  upwards  and  backwards,  then  still  back- 
wards and  a  little  downwards.  By  movement  of  the 
handle  in  this  curve  the  tip  of  the  forceps  is  made  to 
travel  upwards  and  forwards,  and  is  kept  applied  to 
the  fcetal  head  (Fig.  130).  When  the  movement  is 
complete,  the  blade  lies  applied  to  the  fcetal  head,  at 


Application  of  Forceps. 


37i 


the  left  end  of  the  transverse  diameter  of  the  pelvis 
(Fig.  131). 


\ 


Fig.  131.— Showing  successive  Positions,  1,  2,  3,  of  lower  Blade  of  Forceps 
during  its  Introduction.     (After  R.  Barnes.) 

Now  place  the  back  of  your  left  hand  against  the 
left  blade  of  the  foi-ceps,  and  thus  hold  it  in  position. 
Keep  the  index  and  middle  fingers  applied  to  the  os 


372 


Difficult  Labour. 


uteri  or  to  the  head,  as  you  did  in  introducing  the 
lower  blade.  Pass  the  upper  blade,  like  the  lower,  at 
first  parallel  with  the  antero-posterior  axis  of  the 
pelvis,  till  its  tip  comes  in  contact  with  the  right 
sacro-sciatic  ligament  (Fig.  132).  Then  make  the 
handle  move  in  a  curve  first  downwards  and  back- 
wards, pressing  the  tip  gently  on  at  the  same  time, 


Fig  132. — Showing  last  Stage  of  Introduction  of  lower  Blade  of  Forceps, 
and  first  Stage  of  Introduction  of  upper  Blade :  handle  of  first  blade 
well  back  ;  second  blade  entered  in  anteroposterior  direction,  tip  im- 
pinging on  right  sacro-sciatic  ligament.    (AJter  R.  Lames.) 


then  still  backwards,  but  upwards,  until  its  handle 
arrives  close  to  the  handle  of  the  lower  blade  (Fig.  133). 
If  they  have  been  properly  introduced,  they  will 
easily  lock. 

The  advantage  of  introducing  the  blades  in  this 
way  instead  of  passing  them  directly  up  the  sides  of 
the  pelvis,   is  that  to  pass  the  upper  blade  directly 


Application  of  Forceps. 


373 


into  its  side  of  the  pelvis  the  handle  must  be  so  far 
depressed  that  unless  the  patient's  pelvis  be  almost 
overhanging  the  side  of  the  bed,  the  bed  will  prevent 


"**=» 


Fig.  133.— Showing  successive  Positions,  1,  2,  of  upper  Blade  of  Forceps 

during  its  Introduction.    (After  R.  Barnes  ) 

*  Lower  blade  already  in  position. 


the  handle  from  being  lowered  far  enough.  But  if 
passed  first  in  the  antero-posterior  direction  it  is 
immaterial,  so  long  as  the  patient  is  within  reach, 


374 


Difficult  Labour. 


whether  the  pelvis  is  near  or  far  from  the  edge  of 
the  bed  ;  and  thus  much  trouble  in  putting  and  keep- 
ing the  patient  in  position  is  avoided.  This  mode  of 
introducing  the  forceps  is  called  on  the  Continent  the 
"  manoeuvre  of  Madame  La  Chapelle,"  for  it  was  first 
described  by  her. 


Fig.  134.— Showing  Forceps  locked  and  grasped  by  the  Hands ;    line  of 
traction  as  nearly  as  possible  in  axis  of  brim.    (After  R.  Barnes.) 


If  the  blades  do  not  lock,  the  probability  is  that  it 
is  from  one  or  both  of  them  not  having  been  intro- 
duced far  enough.  If  the  lock  of  one  of  them  is  not 
as  near  the  vulva  as  the  other,  press  this  blade  farther 
up.  If  the  flat  surfaces  of  the  handles  do  not  face 
one  another,  carry  the  handles  well  back.  This  will 
move  the  blades  into  the  sides  of  the  pelvis,  and  when 
they  are  there  the  handles  will  lock. 

Extraction. — The  great  use  of  the  forceps  is  to 


Delivery  with  Forceps. 


375 


pull,  not  to  squeeze.  Put  one  finger  in  the  bow  of 
the  shank,  or  the  index  and  middle  fingers  on  the 
shoulders ;  or  with  both  hands  use  both  ways.  If 
the  head  is  at  the  brim,  pull  as  nearly  in  the  axis  of 
the  brim,  that  is,  a  line  drawn  from  the  umbilicus  to 
the  coccyx,  as  the  perineum  will  let  you  (Fig.  134). 


Fig.  135.- Showing  last  Stage  or  Extraction  ;  the'dotted  line  a  b  shows 
the  "  pendulum  movement."    (After  R.  Barnes.) 


As  the  head  comes  down,  pall  more  forwards,  in  the 
axis  of  the  part  of  the  cavity  in  which  the  head  lies. 
Pull  with  the  paim  ;  leave  oft'  pulling  between  the 
pains. 

Take  care   to  deliver   slowly,   so  as  to  give   the 
perineum  time  to  stretch.     As  the  head  stretches  the 


376 


Difficult  Labour. 


perineum,  change  your  grasp  so  that  the  radial  border 
of  your  right  hand  may  be  towards  the  handle  end, 
and  carry  the  handles  more  and  more  forwards  between 
the  mother's  thighs,  so  as  to  make  the  nape  of  the 
neck  hug  the  symphysis  closely  (Fig.  135).  When 
the  perineum  is  so  far  stretched  that  its  edge  is  over 


Fig.  136  —Showing  how  it  is  possible  to  pull  in  the  Axis  of  the  Pelvic 
Brim  with  the  ordinary  Forceps.  The  left  band  pulls  in  the  direction 
y  d;  the  right  hand  in  the  direction  xf;  if  both  hands;  pull  with 
equal  strength,  and  each  in  the  direction  of  the  corresponding  fore-arm, 
the  resultant  of  the  combined  pull  will  lie  along  the  line  a  r  b,  which 
is  the  axis  of  the  brim.  The  objection  to  this  manoeuvre  is  that  the> 
direction  of  the  fore-arm  is  not  that  in  which  the  operator  can  pull 
best.  To  pull  with  his  full  strength  he  must  pull  his  arms  towards 
his  chest.    (After  Galabin.) 


the  anterior  fontanelle,  separate  the  blades  of  the 
forceps  and  take  them  off.  When  the  head  has  got 
as  far  as  this,  the  tension  of  the  perineum  will  excite 
reflex  action  sufficient  to  expel  the  head.  If  either 
blade  should  not  be  lying  quite  flat  on  the  head  the 
edge  may  cut  the  tense  edge  of  the  perineum,  and  in 


Axis    Traction   Forceps.  377 

any  case  the  blades  take  up  room  and  so  cause  a 
little  extra  stretching  of  the  perineum.  Some  degree 
of  inertia  at  this  time  is  an  advantage,  leading  to 
more  gradual  stretching  of  the  perineum,  and  therefore 
less  risk  of  rupture. 

Axis  traction  forceps. — The  ordinary  forceps 
has  three  defects  :  1.  When  it  is  applied  to  the  head 
above  the  brim  it  is  difficult,  although  possible,  to 
pull  in  the  axis  of  the  brim,  that  is  downwards  and 
backwards.  The  perineum  prevents  the  handles  of 
the  forceps  from  being  carried  sufficiently  far  back 
for  a  straight  pull  to  act  in  the  axis  of  the  brim. 
It  is  possible,  as  the  diagram  by  Galabin  (Fig. 
136)  shows,  to  do  so  by  what  on  the  Continent 
is  called  "  Pajot's  manoeuvre."*  But  when  pulling 
hard  it  is  difficult  not  to  pull  in  the  direction  in 
which  pulling  is  easiest.  This  defect  has  been  over- 
come by  giving  the  shanks  and  handles  of  the 
forceps  a  perineal  curve.  Many  inventors  have  done 
this.     Dauber's  forceps  is  an  instance  (Fig.  128). 

2.  It  is  important  when  delivering  with  forceps 
to  keep  the  blades  flat  to  the  head.  If  you  try  to 
rotate  the  head  with  forceps,  or  if  in  pulling  you 
do  not  hold  the  forceps  loosely  enough  to  follow 
the  head  in  any  turn  it  makes,  an  edge  may  be 
raised  off  the  head  and  cut  the  vagina.  And  by 
not  following  the  rotation  of  the  head,  you  to  some 
extent  hinder  the  rotation. 

3.  If  the  pulling  force  is  to  act  to  the  best  ad- 
vantage it  must  act  in  the  line  of  the  pelvis  axis. 
This  changes  as  the  head  advances.  With  the 
ordinary  forceps  the  operator  must  judge  where 
the  head  is,  and  therefore  in  what  direction  he 
ought  to  pull.  He  has  no  guide  except  feeling  or 
seeing  the  head. 

Advantages  of  axis  traction  forceps.— The 


*  This  manoeuvre  was  independently  described  by  Pajot  and 
Galabin  at  about  the  same  date.  But  Galabin  gave  the  mathe- 
matical explanation  of  its  effect. 


378 


Difficult  Labour. 


o,xis  traction   forceps,   designed  by  Prof.   Tarnier  of 
Paris,   and    modified   in   small    details   by   others,  is 

almost  without  these  de- 
fects (Fig.  137).  The 
essential  difference  be- 
tween the  axis  traction 
forceps  and  the  ordinary 
instrument  is,  that  the 
handles  used  in  apply- 
ing the  blades  are  not 
used  for  pulling.  Pull- 
ing is  done  by  a  bar  at- 
tached to  traction  rods : 
and  the  traction  rods 
are  jointed  to  the  blades 
a  little  below  the  part 
that  corresponds  to  the 
equator  of  the  head. 
(Theoretically,  they 

should  be  attached  op- 
posite the  equator  of 
the  head :  but  this  is 
opposite  the  middle  of 
the  fenestra.)  *  The 
traction  rods  have  a 
perineal  curve.  By  this 
construction  (1)  the 
perineal  curve  makes  it 
possible  to  pull  in  the 
axis  of  the  brim.  (2) 
The  head  is  perfectly 
free  to  turn ;  for  the 
traction  rods  are  jointed 
to  the  blades  so  that  the 
head  can  move  about  a 
transverse  axis,  and  the 
traction  bar  is  jointed  to  the  traction  rods  so  that 
the  head  with  the  forceps  can  move  about  a  vertical 

*  As  to  the  construction  of  axis  traction  forceps  see  papers  by 
Milne  Murray,  Edin.  Med.  Journal,  1891. 


Fig.  137.— Axis  Traction  Forceps  :  pat 
tern  of  Cullingworth. 


Axis  Traction  Forceps. 


379 


axis.  (3)  The  blades  are  fixed  on  the  head  by  a 
screw.  Hence  they  move  as  the  head  moves,  and  the 
direction  of  the  handles  therefore  indicates  the  position 
of  the  head,  and  the  proper  direction  in  which  to  pull. 
In  these  respects  the  axis  traction  forceps  is 
superior  to  the  ordinary  instrument. 

Defects  of  axis  traction  forceps. — The  defects 
of  this  instrument  are  (1)  its  complexity :  the 
number  of  joints  and  crevices  in  which  dirt  may 
lurk,  and  hence  greater  difficulty  in  keeping  it  clean. 
2.  The  continued  compression  of  the  h'ead  while  it  is 
applied.  If  forceps  were  often  required  when  the 
head  is  above  the  brim,  the  advantages  would  out- 
weigh the  defects.  But  in  nineteen  cases  out  of 
twenty  in  which  the  forceps  \s  required  the  head  is 
in  the  pelvic  cavity ;  and  the  ordinary  forceps  will  do 
just  as  well  as  the  axis  traction.  In  most  cases  in 
which  assistance  is  needed  while  the  head  is  above  the 
brim,  turning  is  better  than  any  kind  of  forceps. 

Walcher's  position. — The  sacroiliac  synchon- 
drosis allows  a  little  movement  of  the  pelvis  upon  the 
sacrum :  a  rotation  about  a  transverse  axis  passing 
through  this  joint.  When  the  patient  is  put  on  a  high 
table,  with  her  legs  hanging  down,  the  weight  of  the 
legs  effects  this  rotation,  and  pulls  the  front  part  of 
the  pelvis  down,  lengthening  the  conjugate  diameter 
by  from  one  to  two  fifths  of  an  inch.  This  position 
is  called  "  Walcher's,"  after  the  obstetrician  who 
pointed  out  its  use.  If  the  head  is  at  the  brim,  in 
the  most  favourable  position,  but  enters  not  the 
pelvis,  you  can  help  its  entry  by  putting  the  patient 
into  Walcher's  position. 


380 


CHAPTER  XXVI. 

TURNING. 

Turning  means  changing  the  position  of  the  child, 
so  as  to  make  the  head  or  the  breech  present  instead 
of  the  part  that  at  first  presented.  The  latter  clause 
is  necessary  to  the  definition,  because  it  is  not  usual 
to  describe  under  the  head  of  turning  the  rotation  of 
the  head  so  as  to  get  the  occiput  or  chin  forwards,  the 
bringing  down  of  the  arms,  the  flexion  of  the  after- 
coming  head  with  the  finger  in  the  mouth,  or  other 
minor  manipulations,  although  all  these  effect  changes 
in  the  position  of  the  child  more  favourable  to  delivery. 

Indications  for  turning. — 1.  The  chief  indica- 
tion for  version  is  transverse  presentation.  Here  the 
position  of  the  child  must  be  changed,  or  it  cannot  be 
born — unless  there  be  some  exceptional  features,  such 
as  smallness  of  the  child,  or  unusual  strength  of  the 
pains.  Of  course  it  is  not  necessary  to  turn  a  six- 
months'  child.  But  in  the  case  of  a  child  transversely 
presenting  at  or  near  term  the  chances  are  so  much 
against  its  being  born  naturally,  that  turning  is 
imperative. 

2.  In  placenta  prmvia.  The  object  of  turning 
here  is  to  get  a  part  of  the  child's  body  into  the  os, 
so  that  it  may  press  upon  the  vessels  laid  open  by  the 
separation  of  the  placenta,  and  thus  stop  bleeding, 
and  that  at  the  same  time  the  thigh  and  half-breech 
(if  the  child  may  form  a  soft  and  safe  dilator  for  the 
cervix. 

3.  In  the  flat  pelvis  when  the  head  is  presenting, 
and  is  not  in  the  most  favourable  position  for  forceps 
delivery ;  and  the  degree  of  contraction  is  not  such 
that  craniotomy  is  required — that  is,  the  conjugate 
diameter  measures  at  leasi  three  inches.  The  bones 
of  the  head  are  more  easily  compressed  when  the  head 


Indications  for    Turning.  381 

comes  through  base  first  than  when  the  vertex  comes 
first,  because  in  the  former  case  the  parietal  bones 
are  pressed  together  so  that  they  meet  one  another  at 
a  more  acute  angle,  and  thus  diminish  the  transverse 
diameter  of  the  head.     (See  Fig.  86,  page  206.) 

In  these  cases  the  two  following  indications  will 
often  be  present,  viz. 

4.  In  face  presentation,  when  attempts  at 
changing  a  face  presentation  into  a  vertex  have  failed, 
and  the  face  does  not  engage  in  the  brim,  and  there- 
fore does  not  come  down  into  the  os  uteri  to  dilate  it ; 
and  there  yet  appears  to  be  room  enough  in  the  pelvis 
for  a  living  child  to  pass. 

5.  In  prolapse  of  the  funis,  when  the  funis  cannot 
be  replaced,  or  will  not  stay  up  when  replaced,  and 
the  evident  cause  of  the  prolapse  is  that  the  head  does 
not  come  down  into  the  brim. 

6.  In  cases  of  accidental  haemorrhage  in  which  the 
head  is  not  presenting,  it  is  well  to  turn  and  get  the 
head  or  breech  over  the  os,  or  the  leg  into  the  os,  at 
the  same  time  that  you  rupture  the  membranes. 

7.  Lastly,  as  turning  is  the  best  way  in  which, 
without  instruments,  you  can  hasten  delivery ;  as  in 
most  of  the  rarer  kinds  of  obstruction  to  delivery 
turning  is  the  best  practice ;  and  as  delivery  by  forceps 
is  only  indicated  when  you  are  sure  that  the  head  is 
in  a  favourable  position  for  passing  through  the  pelvis  ; 
it  may  be  laid  down  as  a  practical  precept  in  difficult 
labour — when  in  doubt,  turn.  But  the  cases  in  which 
you  turn  because  you  are  in  doubt  ought  to  be  rare. 

Turning  is  an  operation  which  per  se  is  without 
danger  to  the  child.  Nevertheless  many  children 
delivered  in  this  way  are  killed  in  the  birth.  It  is 
extraction,  not  turning,  that  is  dangerous.  Therefore, 
if  you  can  possibly  avoid  it,  do  not  turn  until  the 
cervical  canal  is  so  dilated  that  you  can,  after  turning, 
deliver  quickly. 

As  the  usual  indication  for  turning  is  a  trans- 
verse presentation,  I  shall  describe  the  operation  as  it 
is  done  in  a  case  of  this  kind. 


382  Difficult  Labour. 

Modes  of  turning. — There  are  three  ways  of 
turning  the  child. 

1.  By  external  manipulation  alone. 

2.  By  combined  external  and  internal  manipu- 
lation. 

3.  By  internal  manipulation  alone. 

1.  External  version. — This  can,  as  a  rule,  only 
be  done  while  the  membranes  are  unruptured,  and 
there  is  enough  liquor  amnii  for  the  child  to  move 
about  freely.  Exceptionally,  the  uterus  may  be  so  re- 
laxed even  after  rupture  of  the  membranes  as  to  allow 
external  version  to  be  done ;  but  this  is  rare.  You 
may  do  either  ceplialic  version,  bringing  the  head 
into  the  brim,  or  podalic,  bringing  the  pelvic  end  of 
the  foetus  into  it. 

A.  Cephalic  version. — Put  the  patient  on  her  back, 
with  her  knees  drawn  up.  Let  the  abdomen  be 
uncovered,  and  all  bands  around  the  waist  loosened. 
Empty  the  bladder.  Ascertain  exactly  the  position  of 
the  head,  which,  in  a  transverse  presentation,  will  be 
in  one  iliac  fossa.  Place  one  hand  on  the  side  of  the 
head  farthest  from  the  pelvic  inlet,  and  the  other  on 
the  side  of  the  breech  farthest  from  the  middle  line. 
Then  by  steady  pressure  push  with  one  hand  the  head 
towards  the  pelvic  inlet,  and  with  the  other  the  breech 
upwards  and  towards  the  middle  line.  As  your 
pressure  is  made  on  the  uterus,  and  not  directly  on  the 
child,  its  first  effect  is  to  move  the  uterus  with  the 
child  in  it,  instead  of  the  child  in  the  uterus  ;  and  you 
will  find  that  although  you  seem  to  get  the  child  easily 
into  the  desired  position,  yet  when  you  take  away 
your  hand  it  returns  almost  to  where  it  was  before. 
Therefore  it  is  necessary  to  make  many  pushes,  one 
after  the  other,  to  move  the  child  in  the  uterus. 
When  the  head  has  been  got  over  the  brim,  place  a 
band  on  each  side,  just  above  the  greatest  diameter  of 
the  head,  and  press  the  head  as  far  down  into  the  brim 
as  you  can.  Remember  that  contracted  pelvis  is  one 
of  the  causes  of  transverse  presentation  ;  and  therefore 
that  if  you  cannot  press  the  head  down  into  the  brim, 


External   Version.  383 

it  is  probable  that  the  pelvis  is  contracted.  If,  on  ex- 
amination of  the  pelvis,  you  find  cause  to  think  that 
this  is  the  reason  why  you  cannot  press  the  head  into 
the  brim,  and  yet  that  there  is  not  sufficient  contraction 
clearly  to  indicate  craniotomy,  perform  podalic  version 

If  the  head  has  been  got  into  the  brim,  and  the  os 
uteri  is  dilated  to  as  much  as  three-fifths  of  its  full 
size,  ruptui'e  the  membranes.  If  the  child  bo  lying 
with  its  abdomen  anterior,  after  getting  the  head  into 
the  brim,  before  rupturing  the  membranes  turn  the 
child  round  so  as  to  get  its  back  in  front.  By  letting 
off  the  liquor  amnii  you  enable  the  uterus  to  contract 
upon  the  foetus,  and  drive  it,  instead  of  the  bag  of 
waters,  into  the  os.  Before  the  os  uteri  is  as  large  as 
this,  enough  of  the  head  cannot  enter  the  os  to  make 
it  a  good  dilator. 

When  you  have  got  the  head  into  the  brim  in  a 
favourable  position,  maintain  it  there  by  putting  on  a 
firm  binder.  If  great  obliquity  of  the  uterus  persists 
after  the  malposition  has  been  rectified,  let  the  patient 
lie  on  the  side  opposite  to  that  towards  which  the 
fundus  leans.  The  fundus  will  then  tend  to  fall 
towards  the  side  on  which  the  patient  is  lying,  and  so 
to  undo  the  obliquity  which  may  have  been  the  cause 
of  the  transverse  presentation. 

B.  External  podalic  version  is  performed  in  essen- 
tially the  same  way,  the  only  difference  being  that  in- 
stead of  pressing  the  breech  up  and  the  head  down,  you 
press  the  breech  down  and  the  head  up.  This  opera- 
tion is  seldom  done  by  the  external  method  :  because 
in  most  cases  in  which  podalic  version  is  performed  it 
is  desirable  to  bring  down  a  foot,  and  this  requires 
the  presence  of  two  fingers  in  the  vagina.  Podalic 
version  is  therefore  usually  done  by  the  combined 
method.  But  it  is  practicable,  under  favourable  con- 
ditions, to  do  it  by  the  external  method.  If  the  child 
be  lying  with  the  breech  in  one  iliac  fossa,  and 
there  is  not  enough  liquor  amnii  to  make  the 
child  freely  movable,  it  is  the  best  practice  to 
press    the    breech    into    the    pelvic    brim,    just    as 


3^4 


Difficult  Labour. 


you  would  the  head,  if  the  head  be  the  end  which  is 
the  lower. 

2.  Bipolar  version. — In  the  great  majority  of 
cases  requiring  podalic  version  it  is  possible  to  turn 
by  the  combined  or  bipolar  method,  and  when  this  is 
possible,  it  should  be  the  method  preferred. 


Fig.  138. — Showing  Commencement  of  bipolar  Version,  with  Head  present, 
ing.    The  arrows  indicate  the  direction  of  pushing.    (After  R.  Barnes.) 

'Put  the  patient  either  on  her  left  side  or  on  her 
back.  The  dorsal  position  is  preferable,  but  it  is 
unusual  and  the  patient  may  not  like  it.  If  the 
patient  is  anaesthetised  she  will  be  saved  from  pain, 
and  the  operator's  task  will  be  easier;  but  the 
operation  can  be  done  without  an  anaesthetic. 

Bipolar  version  is  sometimes  called  for  when  the 


Bipolar    Version. 


385 


head  presents  (Fig.  138),  but  more  often  when  the 
shoulder  presents.  Suppose  the  child  lying  with  its 
back  forwards,  head  in  left  iliac  fossa,  and  right 
shoulder  presenting  at  the  os  uteri.  Put  two  fingers 
of  the  left  hand  in  the  vagina,  pass  them  up  through 
the  os  uteri  on  to  the  child's  shoulder.  Place  the 
right  hand  on  the  mother's  abdomen,  over  the  breech 
of  the  child ;  now  with  the  two  fingers  of  the  left 


Fig.  139. — Showing  Commencement  of  bipolar  Version  with  Shoulder  pre- 
senting (second  stage  of  version  when  head  presents).    (After  R.  Barnes.) 

hand  press  the  shoulder  upwards,  forwards,  and  to  the 
left,  at  the  same  time  pressing  the  breech  downwards, 
backwards,  and,  until  the  child's  body  becomes  trans- 
verse, towards  the  right  (Fig.  139).  If  the  mem- 
branes be  not  ruptured,  and  the  liquor  amnii  be  not 
abnormally  deficient,  these  manipulations  will  move 
the  shoulder  away  from  the  os  uteri,  towards  the 
left,  make  the  head  travel  upwards,  the  shoulder  to 
the  left,  and  the  breech  down. 

The  vaginal  fingers  will  then  come  upon  the  ribs 
instead  of  the  shoulder.     Using  a  rib  as  a  point  of 
z— 36 


$86  Difficult  Labour. 

support  for  tbe  fingers,  push  the  chest  along  to  the 
left,  helping  the  movement  with  the  hand  outside. 
The  trunk  of  the  foetus  being  thus  pressed  along 
from  right  to  left,  the  next  part  of  it  felt  will  be  the 
iliac  crest,  and  then  the  fold  between  the  thigh  and 
the  belly.  When  these  parts  are  felt,  press  the 
iliac  bone  upwards  and    forwards  instead  of  to  the 


Fig.  140. — Showing  Continuation  of  bipolar  Version:    seizure  of  knee 
(After  R.  Barnes.) 

left,  at  the  same  time  pressing  the  left  side  of  the 
breech  with  the  external  hand  backwards  and  down- 
wards. Thus  you  will  get  the  abdominal  surface  of 
the  fcetus  to  look  more  downwards,  and  be  able  to 
pass  your  fingers  along  the  thigh  to  the  knee  (Fig.  140). 
When  you  can  feel  the  knee,  press  the  child's  body 
strongly  down  with  the  external  hand,  so  as  to  bring  it 
more  within  reach  of  the  vaginal  fingers.  Then  hook  a 
finger  over  a  knee,  and  draw  it  to  the  os  uteri.  Place 
a  finger  on  each  side  of  the  leg,  and  move  them  down  to 
the  ankle.  Grasp  the  leg  with  two  fingers,  either  one 
above  each  malleolus,  or  one  above  the  heel  and  one 
over  the  front  of  the  ankle,  and  pull  it  down  through 


Bipolar    Version. 


387 


the  os  uteri  (Fig.  141).  In  doing  this  the  membranes 
will  be  ruptured,  if  they  have  not  already  been  torn 
in  hooking  down  the  knee  or  in  grasping  the  foot. 

If  the  membranes  have  been  ruptured,  the  mode  of 
operating  is  the  same,  but  the  child  will  be  moved 
with   more   difficulty.     Although  it  may  be  possible 


Fig.  141,— Showing  final  Stage  of  bipolar  Version:  bringing  down  a  leg- 
(After  R.  Barnes.) 

to  move  the  shoulder,  yet  the  movement  imparted  to 
the  head  may  simply  move  the  uterine  wall  instead  of 
the  head  moving  within  the  uterus.  If  this  be  so, 
place  the  outside  hand  on  the  left  iliac  region  over 
the  head,  and  when  the  fingers  in  the  vagina  move 
the  shoulder,  press  the  head  up  with  the  outside  hand. 
At  the  same  time  get  an  assistant  or  the  nurse  to 
press  down  the  breech.     If  you  cannot  succeed  in  this 


388  Difficult  Labour. 

way  in  moving   the  head,  the  case  is  one   not    for 
bipolar,  but  for  internal  version. 

3.  Internal  version.— Put  the  thumVand  four 
fingers  together  into  a  cone.  Lubricate  the  whole 
hand  with  glycerine  of  sublimate,  and  pass  it  into  the 
vagina.  Then  separating  the  fingers  and  thumb  so  as 
to  make  the  hand  flat,  pass  it  up  along  the  ventral 
aspect  of  the  child.  If  the  arm  be  not  prolapsed,  take 
hold  of  the  arm  which  is  the  lower,  bring  it  down,  and 


Fig.  142.— 8howing  internal  Version.    (After  R.  Barnes.) 

put  a  noose  of  tape  round  it.  Then  pass  up  your  hand 
again  along  the  ventral  aspect  of  the  child,  grasp  the 
knee,  and  pull  it  down  (Fig.  142).  Then  slide  your 
grasp  down  the  leg  to  the  foot,  and  bring  it  down. 
Now  draw  on  the  foot,  at  the  same  time  that  with  the 
hand  on  the  abdomen  you  pi-ess  up  the  head.  In  a 
case  at  which  the  operation  has  been  done  at  the  right 
time,  the  head  will  rise  as  the  other  extremity  of  the 
foetus  is  pulled  down.  When  you  have  got  the  breech 
into  the  pelvis,  deliver  just  as  in  a  breech  presentation. 
The  possible  difficulties  in  extraction  and  the  way 
of  meeting  them  are  the  same  as  in  a  breech  case, 


Internal   Version.  389 

except  that  trouble  in  bringing  down  the  arms  is 
avoided,  because  the  noose  you  have  put  around  the 
lowermost  arm  enables  you  to  pull  that  down  without 
difficulty. 

All  the  manipulations  of  turning  should  be  done 
in  the  intervals  between  the  pains  :  when  a  pain  comes 
on,  desist.  The  reverse  rule  applies  to  extraction  ; 
when  doing  this,  pull  during  the  pains ;  leave  off  in 
the  intervals. 

Which  leg  to  seize.  —  There  has  been  some 
discussion  as  to  which  leg  to  seize.  For  many  genera- 
tions no  one  troubled  about  it ;  accoucheurs  took  the 
first  they  laid  hold  of.  Then  it  was  urged  as  being 
important  that  the  leg  seized  should  be  the  one  op- 
posite to  the  presenting  shoulder,  because,  it  was  said, 
the  child  then  underwent  a  more  complete  change  in 
position,  and  the  shoulder  was  more  effectually  raised 
out  of  the  pelvis.  It  was  assumed  that  the  child  rotated 
about  an  axis  running  from  side  to  side.  Thus 
supposing  the  child  to  be  lying  with  its  abdomen  in 
front  and  its  right  shoulder  presenting,  it  was  assumed 
that  by  pulling  down  the  left  leg  the  left  side  of  the 
body  was  drawn  down  with  that  leg,  the  right  side  of 
the  body  was  made  to  ascend  with  the  right  arm,  and 
thus  not  only  was  the  leg  brought  down,  but  the  back 
was  brought  in  front.  It  was  said  that  if  now  in  such 
a  case  the  right  leg  were  seized,  the  child  rotated 
about  an  axis  running  from  before  backwards :  that  is, 
the  right  leg  was  pulled  down  and  the  right  arm  rose 
up,  but  the  child's  abdomen  remained  in  front.  This 
theoretical  effect  of  seizing  the  leg  opposite  to  the 
presenting  shoulder  led  some,  while  allowing  that  the 
seizure  of  the  lower  leg  was  right  when  the  back  was 
in  front,  to  teach  that  the  opposite  leg  should  always 
be  taken  when  the  abdomen  was  in  front. 

This  teaching  has  been  shown  to  be  erroneous. 
Firstly,  in  practice  it  is  not  only  easier  to  reach  the  leg 
on  the  same  side  as  the  presenting  arm  than  the  other 
leg,  but  easier  to  turn  the  child  when  this  leg  has  been 
seized.     Secondly,  when  the  abdomen  is  in  front  and 


39°  Difficult  Labour. 

the  leg  opposite  to  the  presenting  shoulder  has  been 
brought  down,  the  abdomen  is  often  still   in   front, 


Fig.  143.  —Showing  Fixation  of  Shoulder  below  Os  Internum. 
(Drown  by  Dr.  W.  A.  Kibbler.) 

N.B.— This  figure  shows  the  usual  position  of  the  child  in  transverse  pre- 
sentations more  accurately  than  any  of  the  preceding  ones.  Observe  that  the 
long  axis  of  the  uterus  is  but  little  altered  in  direction. 

showing  that  the  supposed  complete  rotation  of  the 
child's  body  about  an  axis  running  from  side  to  side 
does    not   always   take    place.      Thirdly,   it   is   not 


Difficulty  in  Rotation.  391 

important  that  it  should  take  place ;  for  the  leg  that  has 
been  brought  down  will  always  during  delivery  move 
to  the  front,  no  matter  what  was  the  position  of  the 
child  at  the  time  the  leg  was  brought  down.  Galabin* 
has  shown  that  there  is  a  distinct  mechanical  advan- 
tage in  version  by  the  leg  on  the  same  side  as  the 
presenting  part.  Practice  and  theory  thus  go  together 
in  showing  that  the  right  leg  to  seize  is  the  one  most 
easily  got  at,  and  that  is  the  leg  on  the  same  side  as 
the  presenting  shoulder. 

Difficulty  in  rotation. — If  the  membranes  have 
long  been  ruptured,  almost  all  the  liquor  amnii  will 
have  run  away.  Then  the  uterus  will  closely  embrace 
the  child,  having  become  moulded  to  its  shape.  If 
this  is  the  case,  you  may  find  that  although  you  can 
seize  a  foot,  the  child  does  not  turn  when  you  pull  on 
the  foot.  In  that  case  put  over  the  ankle  a  noose  of 
tape  and  pull  on  this,  using  the  hand  in  the  uterus  to 
push  up  the  shoulder  and  head  of  the  child. 

Fixation  of  shoulder  below  os  internum. — If 

the  shoulder  has  been  driven  down  before  the  full  dilata- 
tion of  the  os  internum,  the  point  of  the  shoulder  may 
get  caught  below  the  os  internum,  which  grips  the  neck 
of  the  child,  and  then  the  child  cannot  be  turned  in  the 
way  described,  because  pushing  the  shoulder  up  only 
presses  it  more  strongly  against  the  os  internum 
(Fig.  143).  If  you  cannot  make  the  child  turn, 
examine  carefully,  and  if  this  condition  be  the  cause 
of  the  difficulty,  you  will  feel  the  ring  of  the  os 
internum.  (Possibly  this  effect  might  be  produced 
by  a  retraction  ring  formed  during  a  long  labour 
above  the  internal  os.  In  the  cases  I  have  seen,  the 
ring  was  not  high  enough  up  for  this.)  If  you  recog- 
nise the  difficulty,  it  is  easy  to  overcome  it.  Press 
the  point  of  the  shoulder  towards  the  middle  line. 
You  will  thus  disengage  it  from  the  impediment 
which  prevented  it  from  rising,  and  by  pulling  on  the 
leg  you  will  turn  the  child  without  difficulty. 

*  Obst.  Trans.,  voL  xix. 


39* 


CHAPTER   XXVI L 

OPERATIONS    FOR    LESSENING   THE   CHILD'8   SIZE. 

Indications. — These  are  contraction  of  the  pelvio 
canal,  either  by  deformity  or  by  tumours,  and  excessive 
size  of  the  child,  causing  such  disproportion  between 
the  genital  canal  and  the  child,  that  although  a  living 
child  cannot  pass  through  the  parturient  canal,  yet  a 
child  the  size  of  which  has  been  lessened  to  the  degree 
possible  by  the  means  at  our  disposal  can  be  safely 
pulled  through  it.  The  diagnosis  of  these  conditions 
has  been  described  in  chapters  x.,  xiv.,  xvn.,  and  xix. 

Prognosis. — The  success  of  the  operation  depends 
upon  its  necessity  being  found  out  early,  before  the 
patient's  tissues  have  been  damaged  by  the  pressure  of 
the  child's  head  upon  them  during  prolonged  labour, 
and  before  injury  has  been  inflicted  by  attempts  at 
delivery  in  other  ways.  One  writer  has  succeeded, 
by  collecting  cases  in  which  the  operation  was  im- 
properly postponed  and  antiseptics  neglected,  in  show- 
ing as  its  result  a  mortality  of  50  per  cent.  But  the 
danger  to  the  mother  of  the  operation  done  skilfully, 
in  the  proper  cases,  at  the  proper  time,  and  with  anti- 
septic care,  is  not  higher  than  that  of  natural  labour. 

The  operations. — The  operations  by  which  the 
size  of  the  child  is  lessened  are,  1 ,  per/oration  of  the 
head,  followed  if  necessary  by  either  (a)  craniotomy 
or,  as  it  is  sometimes  called,  cranioclasm,  or  (b)  cephalo- 
tripsy;  2,  evisceration,  which  means  emptying  the  chest 
or  belly ;  3,  decapitation.  The  two  latter  may  be  grouped 
together  under  the  title  of  embryotomy.  Other  methods 
of  lessening  the  size  of  the  child  have  been  invented, 
such  as  basilysis,  which  is  breaking  up  the  base  of  the 
skull  by  a  sort  of  large  gimlet  called  a  basilyst ;  cutting 
the  head  into  sections  with  a  chain  saw  or  steel  wire ; 
hut  none    has  been   shown  to  have  any  advantage 


Perforation. 


393 


over  those  commonly  in  use.     I  shall  only  describe 
those  which  experience  has  shown  to  be  the  best. 

Perforation. — Perforation   is   the   first   step   in 
lessening   the  size  of  the  child's  head.     You  cannot 
crush  the  child's  head  until 
it   has   been    perforated,  on 
account  of  the  resistance  of 
its  contents. 

The  perforator.— The 
best  perforator  is  Oldham's 
(Fig.  144).  It,  like  most 
perforators,  consists  of  two 
pieces  jointed  together  so 
that  they  form  a  sharp- 
pointed  head,  mounted  on  a 
strong  handle  so  made  that 
after  a  hole  has  been  made 
by  the  head  of  the  instru- 
ment the  two  halves  can  be 
separated  and  the  hole  en- 
larged. Oldham's  perforator 
is  straight ;  a  curve  is  unne- 
cessary, and  gives  a  tendency 
to  slip.  Some  perforators 
have  the  whole  of  the  point 
attached  to  one  blade,  the 
other  being  truncated.  This 
is  not  an  improvement. 
Some  perforators  are  made 
with  scissor-handles,  others 
with  handles  kept  apart  by 
a  spring  or  bar;  but  these 
are  inferior  in  strength,  sim- 
plicity, and  convenience  to  Oldham's.  You  cannot  hold 
the  scissor-handles  so  well.  The  instrument  in  which  the 
handles  are  kept  apart  by  a  spring  or  bar  obliges  you  to 
take  away  the  fingers  which  are  informing  you  of  the 
position  of  the  point,  in  order  to  unfix  the  spring  or 
bar.  In  choosing  an  Oldham's  perforator,  see  that  the 
distance  between  the  handles  fits  the  size  of  your  hand. 


Fig.  144.  —Oldham's  Perforator 


394  Difficult  Labour. 

Where  to  perforate.  —  Some  writers  have 
advised  perforation  through  the  bony  vault ;  others 
through  .a  suture  or  fontanelle.  It  takes  a  little 
longer  to  get  through  a  bone,  but  the  hole  made  in  a 
bone  remains  open ;  it  does  not  get  stopped  up  by  a 
valve  of  membrane.  It  is  easier  to  get  through  a 
^^.  fontanelle ;  but  the  margins  of  an  opening 

[AA  made  through  membrane  may  fall  together 
\  enough  to  impede  the  free  exit  of  brain 
matter.  Therefore  if  you  have  a  proper 
instrument  perforate  through  the  bone.  If 
you  have  not  got  with  you  a  perforator, 
you  can  make  an  opening  through  a  suture 
or  fontanelle  with  pocket-knife  or  scissors. 
How  to  perforate. — Ascertain  the 
position  of  the  cervix  uteri.  Place  two 
fingers  on  the  most  advanced  part  of  the 
head  so  that  their  backs  may  be  in  contact 
with  the  cervix,  if  it  be  not  retracted. 
Then  pass  up  the  point  of  the  perforator 
in  the  recess  between  the  palmar  surfaces 
of  the  fingers.  When  it  strikes  the  head, 
with  a  combined  pushing  and  boring  move- 
tv£-  ment  push  it  through  the  skull  up  to  the 

X^n       shoulder  of  the  instrument.    Then  separate 
^^^    the  blades  so  as  to  make  a  free  opening. 
Close  the  blades  again,  turn  the  instrument 
cfotciietT    through  a  right  angle,  and  make  another 
free  opening.    Now  take  the  crotchet  (Fig. 
145),  put  it  in  through  the  hole,  and  break  up  the 
brain,  taking  especial    care   to   destroy  the  medulla 
oblongata.     The  crotchet  is  best  for  this  purpose,  for 
if  you  use  the  perforator  its  point  is  apt  to  catch  in 
the  dura  mater.     If  you  do  not  break  up  the  medulla, 
the  child  may  breathe  and  cry  after  it  is  born,  al- 
though the  upper  part  of  its  brain  ha3  been  broken  up. 
Methods     Of     extraction.  —  Extraction,    after 
perforation,  is  done  with  one  of  two  instruments  :  (a) 
the  craniotomy   forceps,   which    is    also    called    the 
cranioclast,  and    (6)    the  cephalotribe.      In    different 


Craniotomy.  395 

books  you  find  different  opinions,  some  writers  think- 
ing that  for  one  who  has  a  cephalotribe  the  craniotomy 
forceps  is  unnecessary ;  others  that  the  cranioclast  has 
made  the  cephalotribe  obsolete.  The  truth  is  that  it 
is  hardly  possible  for  the  two  instruments  to  be  com- 
pared ;  for  the  results  attained  depend  more  on  the 
skill  and  practice  of  the  operator  than  on  his  instru- 
ment. Cases  calling  for  perforation  are  not  very 
common.  One  who  has  become  dexterous  in  the  use  of 
the  cephalotribe,  and  then  attempts  to  use  the  cranio- 
clast for  the  first  time,  is  hardly  likely  to  be  pleased 
with  it,  and  is  not  able  to  give  an  unbiassed  judgment. 
Mutatis  mutandis,  the  same  thing  holds  of  one  who 
has  become  skilful  with  the  craniotomy  forceps,  and 
then  tries  to  use  the  cephalotribe.  Humanity  as  well 
as  care  for  his  reputation  will  prevent  one  accustomed 
to  either  instrument  from  risking  injury  to  his 
patients  for  the  sake  of  practice  with  what  will  seem 
to  him  an  awkward  instrument. 

My  own  preference  is  for  the  cephalotribe  in  bad 
cases;  but  this  may  be  because  I  have  used  it  so 
much  oftener.  It  is,  I  believe,  possible  in  cases  of 
extreme  pelvic  contraction  to  deliver  through  a 
slightly  smaller  space  with  the  craniotomy  forceps 
than  with  the  cephalotribe.  In  sught  cases  the 
craniotomy  forceps  is  easier  to  use.  I  advise  you 
not  to  get  both,  but  to  choose  one,  learn  to  use  it 
well,  and  keep  to  it. 

A.  The  craniotomy  forceps  or  cranioclast.— 

This  is  used  for  one  of  two  purposes  : — 

1.  In  slight  cases  to  pull. 

2.  In  bad  cases  to  break  up  the  cranial  vault. 
The  instrument. — The  craniotomy  forceps  con- 
sists of  two  separate  blades  united  by  a  lock.  The  Eng- 
lish lock  is  the  best  (Fig.  146).  In  many  instruments 
the  blades  are  joined  by  a  pivot  fitting  in  a  slot  (Fig. 
147).  The  blades  have  a  curve  roughly  corresponding 
to  that  of  the  foetal  head,  and  are  serrated,  the  outer 
on  its  concave,  the  inner  on  its  convex  surface,  and 
when  locked  the  serrations  should  fit  into  one  another. 


396 


Difficult  Labour. 


Fig.  140.— Roper's  Craniotomy  Forceps,  with 
English  Lock. 


and    the    cervix   uteri 


The  two  blades, 
when  pressed  into 
contact,  are  so 
shaped  that  be- 
tween the  serrated 
part  of  the  blades 
and  the  lock  there 
is  an  interval  at 
which  they  are  se- 
parated, in  which 
a  fold  of  the  scalp 
may  lie  which 
would  otherwise 
interfere  with  ap- 
proximation of  the 
serrated  surfaces. 
The  handles  are 
undulated  on  the 
surface,  and  can 
be  pressed  together 
by  a  screw,  which 
should  be  hinged 
to  one  blade ;  for 
it  is  inconvenient 
to  have  to  hunt 
for  the  screw  when 
you  have  got  the 
blades  into  position. 
This  when  screwed 
home  should  bring 
the  blades  into 
close  contact. 

Its    use.      1. 

Pulling.  —  After 
perforation,  pass 
up  the  outer  blade 
over  one  of  the 
frontal  bones  be- 
tween the  scalp 
Put   the   inner   blade  into 


Craniotomy. 


397 


the  hole  in  the  skull,  and  lock  it  with  the  outer ; 
then  screw  the  handles  together  as  tightly  as  you 
can.  If  the  instrument 
is  well  made,  you  have 
now  a  firm  grasp  of  the 
head.  All  you  have  to 
do  is  to  pull.  If  you  do 
not  succeed,  take  off  the 
instrument  and  apply  it 
again,  this  time  over  the 
occiput  or  over  a  parietal 
bone.  The  diameter  of 
the  incompressible  base  of 
the  skull  is  from  three 
inches  to  three  inches  and 
a  quarter,  measured  either 
between  the  mastoid  or 
the  zygomatic  processes. 
If  the  base  of  the  skull 
be  tilted  towards  either 
shoulder,  so  that  the  two 
ends  of  its  transverse 
measurement  do  not  en- 
sage  in  the  brim  at  the 
same  time,  it  can  easily 
come  through  a  brim  of 
two  inches  and  a  half; 
and  the  vault  of  the 
skull  will  readily  collapse 
to  this  extent  under  pres- 
sure. Therefore  if  the 
conjugate  is  two  inches 
and  a  half  or  more,  and 
the  other  diameters  not 
greatly  contracted,  it  is 
not  necessary  to  break 
up  the  cranial  vault;  it 

is    enough     to     perforate,     pivot  and  Slot,  and  Screw  attached. 

seize  the  head,  and  pull. 

The  pressure  of  the  pelvic  bones  on  the  head  will 


398  Difficult  Labour. 

give  it  the  needful  obliquity,  press  together  the  bones 
of  the  vault  and  press  out  the  brain  substance.  In 
cases  of  slight  contraction,  delivery  in  this  way  with 
the  craniotomy  forceps  is  easy. 

2.  Cranioclasm. — If  the  pelvis  is  smaller  than 
this,  it  will  probably  be  necessary  to  do  more — to  break 
up  the  cranial  vault :  that  is,  cranioclasm. 
£\  The  word  "  probably "  is  inserted  because 

the  necessity  for  the  operation  is  conditioned 
not  only  by  the  size  of  the  pelvis,  but  the 
size  and  degree  of  ossification  of  the  head. 
If  the   head  be  small  and  soft,  it  can  be 
dragged  through  a  smaller  brim  than  one 
having  a  conjugate  of  two  inches  and  a  half. 
If  cranioclasm  is  needed,  push  the  outer 
blade  up  between  the  scalp  and  a  cranial 
bone.      Put  the   inner   blade  through  the 
hole  into  the  skull.     Lock  the  blades,  and 
screw  them  tight.     Now  sharply  twist  the 
instrument,  first  one  way,  then  the  other, 
so  as  to  break  off  the  bit  of  bone  in  the 
grasp  of  the  instrument.     This  done,  with- 
draw the  instrument,  with  the  bone  in  its 
grasp,  guarding  it  with  the  fingers  of  your 
left  hand  to  prevent  splinters  from  scratch- 
ing the  vagina.     In  this  way  seize,  break 
off,    and    extract    pieces    of    the    parietal, 
frontal,  and   occipital  bones.      Having   so 
broken  up  the  vault  of  the  skull  that  the 
Fig.  148.—   fragments  of  the  bones  which  remain  will 
Vertebral   ^e  ^a*  agams*  ^s  base,  put  two  fingei-s  of 
Hook.       the  left  hand  into  the  vagina,  and  the  right 
hand  outside,  and  by  their  combined  opera- 
tion change  the  position  of  the  head  till  the  face  is 
over  the  brim.     As  soon  as  this  is  done,  take  the 
vertebral  hook  (Fig.  148),  and  fasten  it  either  in  the 
mouth,  behind  the  palate  or  lower  jaw — or  in  the 
base  of  the  skull,  behind  the  clinoid  processes  or  in 
the  foramen  magnum — and  thus  draw  down  the  face 
into  the  brim.     If  there  is  difficulty  in  thus  dragging  it 


Cramoclasm. 


399 


through,  hold  the  face  in  the  brim  with  the  hook  in 
the  mouth,  and  then  apply  the  cranioclast  with  one 
blade  under  the  chin,  the  other  above  the  base  of  the 
skull,  and  screw  it  up  as  tightly  as  you  can,  to  crush 
as  much  as  possible,  and  get  a  firm  grip  (Fig.  149) ; 


Fig.  140.— Showing  the  Base  of  the  Skull  seized  by  the  Craniotomy  Forceps 
Face  first  after  Removal  of  the  cranial  Vault.    (After  R.  Barnes.) 


and   then,    with    hook    and    forceps,   pull   the   face 
through  (Fig.  150). 

This  is,  in  my  judgment,  a  more  difficult 
and  tedious  operation  than  cephalotripsy,  but  those 
who  have  used  the  cranioclast  much  say,  that  in 
this  way  a  head  can  be  got  through  a  smaller  brim 
than  the  smallest  through  which  a  cephalotribe  will 
deliver. 


/joo 


Difficult  Labour. 


B.  The  cephalotribe :   the  instrument.— I 

think  this  the  easier  instrument  to  use.  The  best 
cephalotribe  is  that  of  Dr.  Braxton  Hicks.  It  is 
formed  of  two  powerful  nickel-plated  steel  blades, 
thick  enough  not  to  yield,  but  lightened  by  being 


Fig.  150.— Showing  the  Bane  of  the  Skull  being  ilrawn  through  the  Brim 

Face  first.    (After  R.  Barnes.) 

a.  Promontory  of  sacrum ;  c,  coccyx. 

grooved  longitudinally  on  the  interior.  The  handles 
are  approximated  by  a  screw.  The  shanks  should 
for  lightness  be  flattened  in  the  direction  contrary 
to  that  of  the  strain  on  them,  thick  in  the  plane 
parallel  to  the  length  of  the  screw  (Fig.  151).     There 


Tub  Cephalotribe. 


401 


should  be  no  spikes,  studs,  or  other  contrivances  to  hold 
the  head  on  the  inside  of  the  blades ;  such  projections 
hinder  introduction  and  are  unnecessary ;  for  the  head 
is  held  by  the  ap- 
proximation of  the 
ends  of  the  blades. 
The  incurved  tips, 
when  the  blades  are 
closed,  should  meet. 
The  greatest  exter- 
nal measurement, 
when  the  blades  are 
closed,  should  not 
exceed  an  inch  and 
a  half. 

Its  use.— The 
cephalotribe  is  in- 
troduced (after  the 
head  has  been  per- 
forated) in  the  samo 
way  as  the  forceps : 
the  lower  blade  first, 
then  the  upper.  It 
is  of  the  first  im- 
portance that  the 
blades  should  seize 
the  head  opposite 
its  greatest  dia- 
meter.  If  the 
blades  lie  in  front 
of  or  behind  the 
equator  of  the  head, 
when  they  are 
screwed  together 
they  will  slip  for- 
wards or  back- 
wards, as  the  case  may  be.  To  make1  sure  that  they  are 
opposite  the  greatest  diameter  of  the  head,  feel  for  th« 
ends  of  the  blades  with  the  hand  on  the  abdomen. 
You  can  easily  feel  them  through  the  abdominal  wall, 

A  A— 36 


Fig.  151— Hicks's  Cephalotribe. 


402 


Difficult  Labour. 


and  find  out  how  they  lie  with  relation  to  the  head. 
If  they  have  not  rightly  seized  the  head,  move  the 
handles  backwards  or  forwards  as  may  be  necessary. 
When  the  blades  are  in  the  right  place,  apply  the  screw 


Fig.  152.— Showing  the  Cephalotribe  applied.    (After  R.  Barries.) 
a,  Promontory  ;  n,  symphysis ;  J  k,  axis  of  brim. 


and  tighten  it  (Fig.  152).  While  screwing  up,  put  the 
hand  on  the  abdomen  from  time  to  time,  to  be  sure 
that  no  slipping  is  taking  place.  When  you  have  had 
some  practice  you  will  find  this  unnecessary,  for  you 


Crfhalotripsy.  4°3 

will  know  whether  the  head  is  rightly  grasped  or  not 
by  the  resistance  to  the  approximation  of  the  blades. 
If  as  you  work  the  screw  the  blades  come  together 
easily,  they  are  slipping.  If  they  are  rightly  in 
place,  the  more  you  tighten  the  greater  will  be  the 
resistance. 

Extraction. — When  you  have  screwed  the  blades 
home — that  is,  as  tightly  as  you  possibly  can,  begin  to 
extract.  The  commonest  pelvis  calling  for  cephalo- 
tripsy  is  the  flat  rickety  pelvis.  Here  the  narrowing 
is  in  the  conjugate.  You  have  crushed  the  head  in 
the  transverse  diameter.  Turn  the  instrument  through 
a  quarter  of  a  circle,  so  as  to  get  the  crushed  part  of 
the  head  into  the  narrow  part  of  the  brim.  Extract 
by  steady  traction.  Take  care  not  to  hold  the 
instrument  so  rigidly  as  to  prevent  the  head  from 
accommodating  itself  to  the  shape  of  the  brim.  If 
the  head  does  not  come  down  easily,  vary  a  little  the 
line  of  traction  from  time  to  time  in  order  that  the 
shape  of  the  crushed  head  may  accommodate  itself  to 
that  of  the  brim.  "With  a  good  cephalotribe  extraction 
through  a  flat  pelvis  having  a  conjugate  of  two  inches 
is  easy. 

Evisceration.  —  The  operation  of  opening  the 
child's  chest  or  abdomen  need  not  detain  us  long.  It 
is  best  done  with  a  pair  of  strong  scissors.  They  need 
not  be  very  long ;  a  length  of  eight  inches  is  quite 
enough.  The  blades  should  be  straight,  for  curved 
blades  are  difficult  to  keep  sharp.  They  should  be  at 
an  obtuse  angle  (on  the  flat)  to  the  handles,  so  that 
the  hand  working  them  may  be  out  of  the  way  of  the 
hand  guiding  them.  Suppose  that  the  case  is  one  of 
enlargement  of  the  child's  body,  preventing  it  from 
passing.  Let  an  assistant  pull  on  the  legs,  so  as  to  get 
the  part  offering  resistance  as  low  down  as  possible. 
Pass  two  fingers  of  the  left  hand  up  to  the  enlarged 
part  of  the  child,  with  their  dorsal  surface  against  the 
pelvic  wall.  Then  pass  up  the  scissors  along  the  palmar 
surface  of  the  fingers,  and  snip  through  the  abdominal 
parietes.     When  you  have  made  an  opening,  insert 


404 


Difficult  Labour. 


your  fingers,  grasp  with  them  whatever  viscus  seeais 
to  hinder  progress,  pull  it  down,  and  cut  it  away. 

Decapitation.  Indications. — This  operation  is 
called  for  chiefly  in  cases  of  transverse  presentation 
in  which  the  liquor  aranii  has  run  off,  and  therefore 
turning  is  difficult ;  and  either  (a)  the  child  is  dead, 
and   you   ought   not   to   expose   the  mother   to   the 


Fig.    153. —  Showing   Wedge-like    Impaction   of  Shoulder    Presentation. 
(After  R.  Barnet.) 

A,  Point  of  wedge ;  b  o,  base  of  wedge ;  m,  brim  of  pelvis ;  k  f.  tine  of  incision 
to  break  up  wedge. 


slightest  risk  for  the  sake  of  delivering  it  unmuti- 
lated ;  or  (b)  the  uterus  has  passed  into  a  state  of 
tonic  contraction,  the  lower  uterine  segment  is  pulled 
up,  stretched,  and  thinned,  and  the  vagina  is  pulled 
up  and  made  tense :  so  that  if  you  try  to  turn,  the 
additional  tension  of  the  genital  canal  which  putting 
in  your  hand  causes  may  lead  to  its  rupture.  When 
the  child  lies  transversely  and  is  forced  down  into  the 


Decapitation.  4°5 

pelvis,  it  forms,  as  R.  Barnes  clearly  puts  it,  a  wedge, 
the  base  of  the  wedge  being  formed  by  the  head  and 
pelvis  of  the  child,  the  apex  of  the  wedge  being  the 
presenting  shoulder  (Fig.  153).  By  cutting  through 
the  neck  you  break  up  the  wedge,  and  delivery 
becomes  easy. 

Decapitation  is  also  called  for  in  certain  cases  of 
locked  twins.  When  vhe  delivery  of  the  child  which 
is  in  advance  is  impeded  by  the  pressure  of  the 
other  child  on  its  neck,  the  way  to  effect  prompt 
delivery  is  evidently  to  divide  the  neck.  The  partly- 
born  child  is  the  one  least  likely  to  be  born  alive,  and, 
therefore,  the  one  to  be  sacrificed.  The  modes  of 
locking  have  been  described  in  chapter  ix. 

The  instrument.  —  The  best  instrument  is 
Ramsbotham's  sharp  hook.  It  should  have  a  cutting, 
not  a  serrated  edge.  Cases  requiring  its  use  occur  so 
seldom  that  you  may  be  years  in  practice  before  you 
have  used  it  often  enough  to  blunt  its  edge.  The 
next  best  instrument  is  a  strong  pair  of  scissors. 
Sawing  through  the  neck  with  a  piece  of  whipcord, 
as  is  sometimes  recommended,  is  a  tedious  process. 

Its  lise. — I  shall  describe  the  operation  as  it  is 
done  in  a  case  of  shoulder  presentation.  If  the 
arm  be  not  already  down,  bring  it  down.  Let  the 
nurse  take  hold  of  it  with  a  napkin,  and  pull  it 
down  as  much  as  possible,  so  as  to  bring  the  neck 
within  reach.  Ramsbotham  recommended  first  put- 
ting a  blunt  hook  over  the  neck  with  which  to  pull 
it  down,  and  then  applying  the  sharp  hook  by  the 
side  of  the  blunt  one.  If  you  can  feel  the  neck  well 
with  your  fingers,  pass  the  sharp  hook  over  it  at 
once ;  but  if  the  neck  is  so  high  up  that  you  cannot 
confidently  guide  the  sharp  hook  over  it,  follow  Rams- 
botham's advice,  and  pull  it  down  with  a  blunt 
hook.  If  you  do  this,  there  is  no  need  for  anyone  to 
pull  on  the  arm.  Pass  up  two  fingers  with  their 
palmar  surface  to  the  back  of  the  child's  neck,  their 
dorsal  surface  to  the  pelvic  wall.  Introduce  the  hook 
with  its   flat  surface  between  these  fingers  and  the 


406 


Difficult  Labour. 


child's  neck.  When  the  end  of  the  hook  is  above  the 
neck,  turn  the  hook  round,  and  depress  it  so  that  its 
concavity  may  encircle  the  neck  (Fig.  154).  Move 
the  guiding  fingers  round  to  the  front  of  the  neck, 
and  feel  the  point  of  the  hook,  so  as  to  be  sure  that 
the  hook  is  over  the  neck.     This  being  certain,  move 


Fig.  154 — Decapitation.    {After  R.  Barnes.) 
The  dotted  line  shows  mode  of  introducing  hook. 


the  hook  quickly  backwards  and  forwards,  at  the 
same  time  pulling  strongly  down.  The  sharp  hook 
properly  applied  will  cut  through  the  neck  in  time 
measurable  by  seconds. 

If  you  have  not  a  sharp  hook,  or  if  you  fail  with 
the    sharp  hook,  as  occasionally   happens,    probably 


Dec  A  PIT  A  TION. 


407 


from  faulty  application,  pull  down  the  neck  with  a 
blunt  hook,  pass  up  two  fingers,  and,  guarded  by 
them,  a  strong  pair  of  scissors,  such  as  you  carry  for 
embryotomy,  and  with  them   cut  through  the  neck 


Fig  155.— Decapitation  :  extraction  of  trunk.    (After  R.  Barntt.) 


by  repeated  snips,  each  snip  being  short  so  that 
you  can  be  sure  what  you  are  cutting  through. 

Extraction  after  decapitation.  —  When  you 

have  cut  through  the  neck,  pull  on  the  arm.  The 
child's  body  and  legs  will  be  delivered  easily  (Fig.  15,5). 
Deliver  the  head  either  with  the  (a)  cephalotribe  or 
(b)  craniotomy  forceps ;  for  this  purpose  the  latter  ia 
the  easier  instrument  to  use.  (a)  With  the  cephalotribe. 
Put  one  hand  (or  two  fingers  may  be  enough)  in  the 
vagina,  the  other  hand  on  the  abdomen.  By  the 
combined  use  of  the  two  hands  turn  the  head  until 


408  Difficult  Labour. 

the  face  is  downwards.  Now  put  the  crotchet,  or  the 
vertebral  hook,  into  the  mouth,  and  hook  it  behind 
the  palate  or  the  lower  jaw.  Having  thus  got  the 
head  fixed  in  the  brim,  apply  the  cephalotribe,  and 
extract  with  it  just  as  in  a  case  in  which  the  head  is 
presenting.  The  brain  matter  will  escape  through  the 
foramen  magnum,  (b)  With  the  craniotomy  forceps. 
Turn  the  head  round  by  the  combined  use  of  the  two 
hands,  until  part  of  the  cranial  vault  is  over  the  brim. 
Then  get  an  assistant,  or  the  nurse,  to  press  it  down 
on  the  brim  by  two  hands  applied  on  the  abdomen. 
While  it  is  thus  held  down,  perforate  it.  Then  apply 
the  craniotomy  forceps — first  a  blade  outside  the  skull, 
then  the  other  in  the  hole  made  by  the  perforator. 
Screw  the  blades  up  as  tightly  as  you  can,  and  pull. 

Division  of  the  vertebrse  elsewhere  than  in  the 
neck  has  been  advised,  under  the  name  spondylotomy; 
but  decapitation  is  easier  and  more  effective  for  the 
purpose  of  delivery. 


40q 


CHAPTER    XXVI11. 

OESAEIAN   SECTION. 

The   indications   for   Caesarian    section  — 

These  are  of  two  kinds :  absolute  and  relative. 
Absolute  indications  are  conditions  which  make 
delivery  in  any  other  way  impossible.  Relative  indi- 
cations are  conditions  in  which  it  is  possible  to 
deliver  in  other  ways,  but  it  is  judged  that  Caesarian 
section  is  the  best,  though  not  the  only  way. 

The  absolute  indications  are  pelvic  deformities 
and  solid  fixed  tumours  in  the  pelvis,  narrowing  the 
space  through  which  the  child  has  to  be  delivered. 
Fluid  tumours  do  not  make  Caesarian  section  neces- 
sary, for  they  can  be  tapped  and  the  fluid  let  out. 
Nor  does  scar  tissue,  for  this  can  be  cut  open  with 
a  knife.  Nor  do  movable  tumours,  for  they  can  be 
pushed  out  of  the  way. 

When  the  room  for  the  passage  of  the  child  is 
in  its  smallest  dimension  less  than  two  inches, 
Caesarian  section  is  absolutely  necessary.  It  may 
be  absolutely  indicated  when  the  smallest  diameter 
is  larger  than  this.  Whether  or  not  depends  upon 
the  degree  to  which  the  space  is  encroached  upon 
in  more  than  one  direction.  The  common  form  of 
pelvic  deformity  which  in  Great  Britain  calls  for 
Caesarian  section  is  the  flat  rickety  pelvis,  and  in 
this  pelvis  the  conjugate  diameter  is  the  one  most 
contracted.  There  is  generally  so  much  room  in 
the  transverse  diameter  that  if  the  conjugate  be 
over  two  inches  delivery  can  be  effected  with  the 
cephalotribe  or  craniotomy  forceps.  It  is  only  in  this 
common  deformity  that  such  a  simple  rule  of  measure- 


4io  Difficult  Labour. 

ment  can  be  laid  down.  In  other  forms  of  pelvic 
deformity,  or  in  tumours  blocking  the  pelvic  cavity, 
you  must  measure  the  available  space  in  all  its 
diameters,  and  judge  of  the  amount  of  injury  which 
will  be  inflicted  in  trying  to  drag  the  child  through. 
The  rarer  forms  of  contracted  pelvis  and  the  possible 
sizes  and  shapes  of  solid  fixed  pelvic  tumours,  alter 
the  size  and  shape  of  the  pelvic  canal  in  such  divers 
ways  that  it  is  not  possible  to  lay  down  absolute 
measurements.  As  a  general  rule,  a  space  of  2  x  4 
inches  represents  the  minimum  through  which  it  is 
prudent  to  attempt  delivery  by  craniotomy. 

Relative  indications. — Caesarian  section  may  be 
relatively  indicated  when  in  a  flat  pelvis  the  conjugate 
diameter  is  more  than  two  inches,  but  less  than  three, 
or  in  a  small  round  pelvis  less  than  three  inches  and 
a  half.  When  the  conjugate  is  above  these  dimensions, 
it  is  possible  that  the  child  may  be  born  alive.  If  it 
is  between  the  dimensions  stated,  the  mother  can  be 
delivered,  by  sacrificing  the  child,  with  no  greater  risk 
than  that  of  normal  labour.  If  we  look  solely  at  the 
immediate  risk  to  the  mother,  craniotomy  must  clearly 
be  the  choice. 

But  there  are  other  considerations  which  may 
incline  us  to  choose  Caesarian  section.  If  the  patient 
can  be  received  into  a  good  hospital,  everything 
prepared  beforehand,  and  the  operation  done  by  an 
experienced  abdominal  surgeon  at  an  appointed  time, 
the  risk  is  small — not  greater  than  that  of  an  ordinary 
ovariotomy.  At  the  time  of  operation  the  patient  can 
be  sterilised  by  removing  the  body  of  the  uterus ; 
while  after  delivery  by  craniotomy  she  is  exposed  to 
the  troubles  and  risks  of  subsequent  pregnancies, 
with  the  prospect  either  of  repeated  craniotomies  or 
of  premature  children  difficult  to  rear.  If  Caesarian 
section  is  done,  the  patient  will  have  as  large  and 
strong  a  child  as  she  can  produce.  If  the  delivery 
be  hindered  by  a  fibroid,  delivery  of  the  child  by 
Caesarian  section  can  be  followed  by  removal  of  the 
uterus  with  the  tumour.     If  the  patient  is  the  subject 


Cms ar i an  Section.  ^j 

of  osteomalacia,  the  disease  can  be  cured  by  removing 
the  ovaries. 

Post-mortem    Caesarian    section.  —  Lastly, 

Caesarian  Section  is  sometimes  required  after  death. 
When  a  pregnant  woman  dies  undelivered,  experience 
has  shown  that  .the  foetus  may  live  as  long  as 
25  minutes  after  the  mother.  Therefore  when  a 
pregnant  woman  dies  undelivered,  from  a  cause — such, 
for  instance,  as  a  fall,  a  burn,  a  crushed  chest,  or  a 
fractured  skull — which  does  not  affect  the  vitality  of 
the  foetus,  the  medical  attendant  ought  to  open  the 
abdomen  as  soon  as  it  is  certain  that  the  mother  has 
breathed  her  last,  in  order  that  the  child's  life  may 
be  saved. 

Time  Of  Operating". — Some  think  it  important 
to  postpone  the  operation  until  labour  has  begun,  for 
the  reasons  (1)  that  the  uterus  contracts  better  after 
labour  has  commenced,  and  (2)  that  the  dilatation  of 
the  cervix  ensures  free  escape  of  the  lochia.  I  do  not 
know  of  any  proof  that  haemorrhage  is  more  likely  to 
occur  when  the  operation  is  done  before  the  beginning 
of  labour  than  when  after  it.  The  advantage  of  doing 
the  operation  at  a  place  and  time  which  make  it  cer- 
tain that  you  will  have  skilful  assistance,  good  light, 
and  every  needful  preparation,  far  outweighs  the  doubt- 
ful liability  to  haemorrhage.  It  is  possible,  however, 
by  putting  a  bougie  or  a  tent  in  the  uterus,  to  start 
labour  pains,  and  yet  operate  at  a  pre-arranged  time  ; 
and  therefore  this  should  be  done.  If  labour  pains 
do  not  come  on  by  the  appointed  time,  and  the 
operation  can  be  postponed  without  forfeiture  of  the 
advantage  of  your  preparations,  postpone  it;  but 
operate  without  labour  pains  rather  than  incur  the 
risk  of  operating  in  unfavourable  circumstances. 

Preparations. — The  patient  should  be  put  on  a 
narrow  table,  with  her  abdomen  uncovered  ;  her  chest 
and  legs  protected  by  warm  clothing.  Macintoshes 
should  be  arranged  so  as  to  protect  the  coverings  of 
the  chest  and  legs  from  being  wetted.  The  position  of 
the  child  should  be  ascertained  by  abdominal  palpation. 


412  Difficult  Labour. 

so  as  to  avoid  spending  time  in  searching  for  the 
knee.  The  bladder  should  be  emptied.  The  abdo- 
men should  be  washed  with  soap  and  water,  and  the 
pubes  shaved,  to  prevent  the  after-dressings  from 
sticking  to  the  haii\  Clean  the  abdominal  wall  with 
turpentine,  ether,  and  1  in  1,000  biniodide  solution. 
Lay  folded  towels,  wrung  out  in  1  in  1,000  biniodide, 
above,  below,  and  on  each  side  of,  the  area  in  which 
the  incision  is  to  be  made. 

Four  assistants  are  required  :  one  to  give  an  anaes- 
thetic ;  one  to  sponge ;  one  to  press  out  the  uterus 
and  keep  the  bowels  back;  and  one  provided  with 
scissors,  thread,  and  a  flannel  receiver,  to  attend  to 
the  baby. 

Instruments  required. — A  scalpel.  Scissors. 
Dissecting  forceps  (those  sold  as  "conjunctiva  for- 
ceps "  are  most  convenient).  Six  small  pressure 
forceps.  Six  large  pressure  forceps  (which  form  the 
best  sponge-holders).  Eighteen  pieces  of  No.  5  China 
twist,  each  piece  eighteen  inches  long,  for  the  deep 
uterine  suture  ind  the  wound  suture.  Twenty-four 
half-curved  No.  1  needles ;  eight  pieces  of  China  twist 
to  be  each  threaded  on  two  needles  (for  the  abdominal 
wound  suture),  and  eight  each  threaded  with  one 
needle  (for  the  deep  uterine  stitches).  A  smaller 
number  of  needles  will  do  if  the  ones  first  used  can 
be  threaded  again  by  the  nurse  during  the  operation. 
A  No.  6  half-curved  needle,  threaded  with  three  feet 
of  No.  1  catgut  (for  the  peritoneal  uterine  suture). 
One  large  flat  sponge,  and  six  round  sponges;  aseptic. 
Gamgee  tissue.  Iodoform.  Binder.  Two  pints  of 
normal  saline  solution.  Biniodide  solution  for  the 
hands. 

The  operation :   opening  the   abdomen.— 

The  patient  having  been  anaesthetised,  make  an 
incision  in  the  middle  line,  about  six  inches  long, 
extending  from  a  little  above  the  umbilicus  to  within 
about  two  inches  of  the  symphisis  pubis.  The  harm 
arising  from  making  the  incision  half  an  inch  too  long 
is  less  than  that   from   too  short  an  incision.      Cut 


Cmsarian  Section.  413 

through  the  skin  and  subcutaneous  fat,  down  to  the 
fascia  forming  the  white  line.  Secure  all  bleeding 
points  with  pressure  forceps.  Then  cut  through 
the  white  line,  and  the  subperitoneal  fat  will  be 
seen.  Take  hold  of  this  with  forceps,  and  pull  it 
up  through  the  wound.  Holding  the  flat  of  the 
scalpel  parallel  with  the  surface  of  the  abdomen,  cut 
carefully  into  the  tissue  pulled  up  by  the  forceps,  and 
when  the  fat  has  been  divided,  the  peritoneum  will  be 
seen.  Make  the  opening  in  the  peritoneum  big  enough 
to  admit  the  finger.  Then  put  a  finger  through  the 
opening,  into  the  peritoneal  cavity;  and,  using  the 
finger  as  a  director,  complete  either  with  knife  or 
with  scissors  the  division  of  the  peritoneum  and  the 
rest  of  the  white  line  throughout  the  whole  length  of 
the  wound. 

Opening  the  Uterus. — Now  let  an  assistant 
with  a  hand  on  each  side  press  the  abdominal  wall 
back  and  against  the  uterus,  so  as  to  make  the  wound 
gape  and  prevent  fluid  getting  into  the  belly.  This 
done,  quickly  cut  into  the  uterus  in  the  line  of  the 
abdominal  wound,  and  for  nearly  the  same  distance. 
If  the  placenta  be  implanted  at  the  site  of  incision,  cut 
through  that  too.  The  uterine  wall  will  bleed  freely 
while  it  is  being  laid  open,  and  if  the  placenta  is  here 
attached,  the  bleeding  will  be  greater.  Therefore  cut 
through  the  uterus  (and  placenta,  if  needful)  as 
quickly  as  you  can. 

Extraction  of  child. — You  will  know  the 
position  of  the  child  from  your  examination  imme- 
diately before  the  operation.  Seize  the  nearest  knee, 
and  extract  the  child.  Hand  it  to  the  assistant  waiting 
for  it.  It  has  been  recommended  to  extract  the  child 
head  first,  because  the  uterus  may  contract  round  the 
neck,  and  so  hinder  the  head  from  coining  out.  The 
way  to  prevent  this  is  to  make  a  long  enough  incision 
before  you  begin  to  extract.  The  knee  gives  much 
the  best  hold. 

Immediately  after  the  child  has  been  extracted,  the 
assistant  who  has  been  keeping  the  abdominal  walls 


414 


Difficult  Labour. 


applied  to  the  uterus  should  press  them  hack  behind 
the  uterus,  so  as  to  turn  it  out  of  the  abdomen. 
The  diminution  in  the  contents  of  the  uterus  by  the 
escape  of  the  liquor  amnii  and  removal  of  the  child 
will  be  followed  by  contraction,  so  that  the  uterus 
will  become  small  enough  to  pass  out  through  the 
incision.  If  this  contraction  is  delayed,  the  pressure 
of  the  assistant's  hands  will  hasten  it.  When  the 
uterus  is  outside,  the  assistant  should  press  the 
abdominal  walls  together  behind  it,  so  as  to  prevent 
the  bowels  from  getting  out. 

Extraction  of  secundines.— Now    put   your 


Fig.  150.— Showing  Position  of  Sutures  in  relation  to  Structures  in  Uterine 
Wall.    (After  Galabin.) 

a,  Peritoneum;  6,  uterine  muscle;  c,  decidua ;  d,  superficial  suture;  e,  deep 
sutures. 


hand  in  the  uterus,  detach  and  remove  the  placenta 
and  membranes.  You  will  probably  find  part  of  the 
placenta  already  detached.  Take  care  to  remove  the 
whole  of  the  membranes.  If  the  uterus  does  not 
contract  well,  and  there  is  haemorrhage,  compress  it 
until  it  does  contract.  Remember  that  the  cut 
uterine  wall  bleeds,  and  that  nothing  but  suture  will 
stop  this.  Make  the  uterus  contract,  and  then  suture 
it ;  but  do  not  postpone  the  suturing  till  all  bleeding 
has  stopped. 

Deep  sutures. — The    uterus  '  being    retracted, 
suture  it.     Put  in  first  from  six  to  eight  deep  sutures 


Uterine  Suture. 


4i5 


at  intervals  of  from  two-thirds  of  an  inch  to  an  inch 
apart.  Take  a  needle  threaded  with  No.  5  china 
twist.  Enter  each  suture  on  the  peritoneal  surface 
about  half  an  inch  from  the  edge  of  the  incision. 
Bring  it  out  through  the  cut  uterine  wall  near  the 
inner  surface,  but  not  including  any  part  of  the  inner 
decidua-covered  surface  (Fig.  156).  Enter  it  again 
on  the  corresponding  spot  of  the  cut  uterine  wall  at 
the  opposite  side,  and  bring  it  out  on  the  peritoneal 
surface  about  half  an  inch  from  the  cut  edge.  Tie 
each  suture  at  once.     In  tying  the  suture,  tuck  in 


\ — -or  N  <t 


Fig.  I5~-  —Showing   the  Sutures   when  tied :   peritoneal  surfaces  being 
brought  into  contact  by  the  superficial  sutures.    (After  Galabin.) 

a.  Peritoneum:  b,  uterine  muscle;  c,  deciJua;  d,  superficial  suture;  e,  deep 
suture. 


the  peritoneal  edges  so  that  the  pull  of  the  knot  may 
bring  peritoneal  surfaces  into  contact. 

Superficial  SUtlireS. — Use  for  these  a  thread 
about  three  feet  long  of  fine  silk  or  No.  1  catgut. 
Enter  the  needle  on  the  peritoneal  surface,  al»out 
one-third  of  an  inch  from  the  line  along  which  the 
deep  sutures  have  brought  the  peritoneal  surfaces  into 
contact.  Bring  it  out  through  the  peritoneum,  close 
to  this  line.  Enter  it  again  close  to  this  line  on  the 
other  side,  and  bring  it  out  about  one-third  of  an  inch 
from  it  (Fig.  157).  Knot  the  first  suture,  cut  off  the 
short  end,  and  then  sew  up  the  whole  line  with  a  con- 
tinuous suture,  each  stitch  being  put  in  as  described, 


416 


Difficult  Labour. 


and  about  a  quarter  of  an  inch  from  the  one  preceding. 

In  putting  in  each  stitch,  before  pulling  out  the  needle 

put  the  thread  outside 
its  point,  making  thus 
what  seamstresses  call 
the  "  button-hole  stitch  " 
(Fig.  158).  This  will 
prevent  the  sutures  from 
lying  obliquely.  The 
advantages  of  this  con- 
tinuous suture  are,  that 
it  is  put  in  more  quickly, 
thus  considerably  short- 
ening the  operation,  and 
that  there  are  fewer 
knots  and  ends  to  be 
covered  with  lymph  and 
absorbed  (Fig.  159). 

Peritoneal  toilette. 

— While  the  uterus  is 
being  sutured,  if  the 
lustre  of  its  peritoneal 
surface  gets  dull  (from 
death  of  the  epithelium 
or  from  adhesion  of 
fibrin  from  the  blood  or 
foreign  matter  from  the 
air)  pour  normal  saline 
solution  over  it  till  it  is 
bright  again.  When  the 
suture  is  finished,  wash 
the  uterus  by  pouring 
saline  solution  over  it 
and  by  sponging  till  it 
is  clean  and  return  it 
within  the  belly. 
If  during  the  operation  any  blood  or  liquor  amnii 
get  into  the  belly  (which  will  not  happen  if  your 
assistant  is  efficient),  wash  out  the  peritoneum  with 
saline  solution.     It  is  not  necessary   to  sponge  out 


Fig.  1.18—  Showing  the 
Stitch. 


1  Button-hole  " 


Mulleks  Modifications.  417 

the   cavity ;    leave    the    fluid    in    it ;    it    will    do   no 
harm. 

Closure  of  abdominal  wound.  —  Now  suture 

the  abdominal  wound.  This  is  best  done  by  having 
on  each  thread  two  half-curved  needles.  Enter  each 
needle  through  the  peritoneum,  close 
to  its  cut  edge,  and  bring  it  out 
at  the  corresponding  point  of  the 
abdominal  wall.  Put  in  six  or  eight 
stitches,  at  from  two-thirds  of  an 
inch  to  an  inch  apart.  Do  not  pull 
them  tighter  than  is  needful  to  secure 
contact,  for  tight  stitches  lead  to  stitch- 
hole  abscesses.  When  you  have  sewn 
up  the  wound,  dust  it  liberally  with 
iodoform,  put  a  thick  pad  of  Gamgee 
tissue  on  it,  and  secure  this  with  a 
binder. 

Muller's  modification  consists  in 

making  a  long  incision,  and  turning  the 
uterus  out  of  the  abdomen  before  cutting 
into  it.  The  supposed  advantage  of  this 
is,  that  the  abdominal  walls  being  held 
together  behind  the  uterus,  blood  and 
amniotic  fluid  do  not  flow  into  the  peri- 
toneal cavity.  But  if  the  abdominal 
walls  are  pressed  close  to  the  uterus,  in 
the  manner  described,  little  or  no  fluid 
will  run  into  the  belly ;  and  whatever 
does  can  easily  be  washed  out  again. 
The  advantage  is  very  slight,  and  is  more 
than  counterbalanced  by  the  longer  ex- 
posure of  the  uterus,  and  by  the  more 
extensive  scar,  which  brings  with  it  a 
greater  liability  to  ventral  hernia. 

The  elastic  ligature. — Another  modification 
introduced  by  Muller,  but  not  necessarily  going  with 
the  long  incision,  is  the  practice  of  putting  an  india- 
rubber  ligature  round  the  cervix  and  pulling  it 
tight  before  opening  the  uterus,  so  as  to  stop  the 

BB— 36 


Fig.  159.  -  Show- 
ing  Wound 
closed  with 
deep  Stitches 
and  superficial 
"Button-hole" 
Stitch. 


4i 8  Difficult  Labour. 

circulation  through  the  uterus.  The  advantage  of  this 
is  that  it  makes  the  loss  of  blood  so  slight  that  the 
operator  can  be  as  deliberate  as  he  pleases.  The 
disadvantage  is  that  the  constriction  of  the  cervix 
and  stoppage  of  the  flow  of  blood  to  the  uterine 
muscle  may  impair  the  contractile  power  of  the  latter ; 
and  this  is  a  most  serious  objection.  And  the  slowness 
in  opening,  emptying,  and  sewing  up  the  uterus,  which 
the  indiarubber  ligature  encourages,  is  not  an  unmixed 
gain ;  for  the  longer  the  peritoneum  is  exposed  and 
handled,  the  greater  the  risk  of  peritonitis.  I  therefore 
advise  against. the  elastic  ligature. 

Cameron's  method  of  using  a  pessary. — 
Dr.  Murdoch  Cameron,  of  Glasgow,  recommends  that 
before  the  uterus  is  opened,  a  ring  pessary  should  be 
pressed  down  upon  it,  so  as  to  press  on  a  circle  of 
tissue  around  the  place  where  the  incision  is  begun. 
By  this  pressure  the  circulation  is  stopped,  and  the 
beginning  of  the  incision  made  almost  bloodless,  so 
that  the  operator  can  clearly  see  when  he  has  got 
down  to  the  foetal  membranes.  When  the  incision  has 
been  made  large  enough  to  admit  the  finger,  the 
operator  can  use  his  finger  as  a  director,  and  rapidly 
complete  the  incision.  This  ingenious  manoeuvre  may 
lessen  a  little  the  amount  of  blood  lost ;  but  the 
quantity  thus  saved  is  not,  if  the  operator  be  skilful, 
very  great. 

Sterilisation, — The  operation  just  described  is 
that  to  which  the  name  Caesarian  section  is  properly 
applied.  It  leaves  the  patient  apt  to  conceive  again. 
She  may  wish  this ;  and  if  so  you  should  leave  the 
ovaries  and  Fallopian  tubes  untouched.  But  if  the 
condition  which  called  for  delivery  in  that  way  is  a 
permanent  one,  and  the  patient  wishes  not  to  again 
run  the  risk  of  Caesarian  section,  I  think  she  is  en- 
titled to  ask  that  she  may  be  made  sterile  for  the 
future.  Except  for  child-bearing  the  uterus  is  use- 
less ;  it  is  liable  to  disease,  and  it  menstruates,  which 
is  a  monthly  illness.  The  danger  of  Caesarian  section 
is  not  increased  by  removing  the  body  of  the  uterus. 


Ster  i  lis  a  tion.  419 

This  is  easy  to  do,  because  the  parts  are  not  distorted 
or  displaced,  so  that  you  know  exactly  where  to  find 
each  structure  that  you  have  to  deal  with.  When  it 
has  been  done  the  patient  is  free  from  child-bearing 
and  menstruation.  Some  think  that  there  is  no 
greater  danger  in  removing  the  whole  uterus  than  in 
removing  its  body  only,  and  they  say  that  as  the 
cervix  is  henceforth  useless,  and  may  get  diseased,  it 
should  be  removed  too.  But  to  remove  the  whole 
uterus  is  more  difficult  than  to  remove  only  the  body, 
because  great  care  is  required  to  avoid  injury  to  the 
ureters.  And  by  leaving  the  cervix  uteri  the  struc- 
ture of  the  pelvic  floor  is  left  unimpaired.  "We  need 
the  history  of  patients  for  many  years  after  complete 
hysterectomy,  to  know  how  much  force  there  is  in 
this  latter  reason  for  leaving  the  cervix.  I  at  present 
think  that  it  is  better  to  leave  the  cervix.  Should  it 
afterwards  become  diseased,  it  can  be  then  removed. 
If  possible  the  wishes  of  the  patient  and  her  husband 
should  be  ascertained  as  to  whether  the  ovaries  should 
be  removed  or  not.  The  evidence  known  to  me 
shows  that  after  the  ovaries  have  been  removed 
sexual  feeling  is  soon  lost,  and  the  genital  organs 
atrophy  as  in  old  women.  On  the  other  hand,  the 
ovaries,  if  left,  may  become  cystic.  The  relative 
importance  of  these  considerations  will  much  depend 
upon  the  age  of  the  patient.  They  should  be  ex- 
plained to  the  patient's  husband,  and  through  him,  if 
possible,  to  the  patient.  If  you  have  to  operate 
without  instructions  on  this  point,  you  had  better 
leave  the  ovaries,  or  at  least  part  of  them.  If  the 
patient  is  suffering  from  osteomalacia,  the  ovaries 
should  be  removed,  for  this  is  the  cure  for  that 
disease. 

If  it  has  been  decided  that  the  patient  shall  be 
sterilised,  instead  of  sewing  up  the  uterine  wound,  let 
your  assistant  stop  bleeding  by  compressing  with  a 
finger  and  thumb  on  each  side  the  uterine  arteries, 
Then  hold  up  and  extend  a  broad  ligament,  so  that 
you  can  see  the  structures  in  it.     At  a  place  where 


420  Difficult  Labour. 

there  are  no  large  vessels,  as  low  down  as  possible, 
push  a  pressure  forceps  through  the  peritoneal  folds. 
Separate  the  handles  of  the  forceps,  and  withdraw  it 
with  its  blades  separated,  thus  tearing  a  hole  in  the 
broad  ligament  large  enough  to  admit  your  finger. 
Through  this  opening  pass  a  double  ligature.  With 
one  ligature  tie  the  ligament  near  the  uterus.  This 
is  not  essential,  but  lessens  slightly  the  loss  of  blood. 
With  the  other  tie  the  broad  ligament  either  on  the 
proximal  or  the  distal  side  of  the  ovary,  according  to 
whether  it  has  been  decided  that  the  ovaries  shall  be 
left  or  removed.  Then  do  the  same  thing  on  the 
other  side.  The  uterus  is  now  attached  only  by  the 
lower  part  of  the  broad  ligaments,  which  contain  the 
uterine  arteries,  and  some  cellular  tissue,  and  in  front 
by  the  round  ligaments.  The  cellular  tissue  at  the 
end  of  pregnancy  is  so  loose  that  you  may  safely 
include  in  one  ligature  peritoneum,  cellular  tissue,  and 
round  ligament,  and  yet  effectively  secure  the  uterine 
artery.  Feel  for  its  pulsation,  pass  the  aneurysm 
needle  below  it,  and  tie  the  whole  mass  of  tissue 
enclosed  by  the  ligature.  If  you  prefer  you  can  tie 
separately  the  round  ligament,  and  divide  it  on  the 
uterine  side  of  the  ligature.  Then  snip  through  with 
scissors  the  peritoneum  in  front  of  the  uterus  along  a 
horizontal  line  just  above  the  vesico-uterine  fold,  and 
strip  it  off  by  pushing  it  down  with  a  sponge.  Then 
you  can  isolate  the  uterine  artery,  and  tie  it  without 
including  more  than  some  cellular  tissue  along  with  it 
in  the  ligature.  This  is  only  necessary  if  the  cellular 
tissue  is  unusually  thick.  When  you  have  tied  the 
uterine  arteries  on  each  side,  cut  off  the  body  of  the 
uterus  by  a  V-shaped  incision,  so  made  that  the  apex 
of  the  V  shall  be  downwards,  and  correspond  to  the 
top  of  the  cervical  canal.  Then  sew  with  catgut 
stitches  the  anterior  flap  underneath  the  posterior,  as 
shown  in  the  diagram  (Fig.  160).  Then  make  the 
peritoneum  clean  and  dry ;  see  that  there  is  no 
haemorrhage,  and  close  the  abdominal  wound  in  the 
way  described. 


Porro's   Operation. 


421 


Recovery  after  this  operation  is  as  easy  as  when 
the  uterine  wound  has  been  sewn  up,  and  should  be 
as  easy  as  after  natural  delivery.  Delivery  in  this 
manner  cannot  be  said  to  be  so  safe  as  natural 
delivery,  because  the  risk  of  intestinal  obstruction  is 
as  yet  inseparable  from  abdominal  section.  After 
abdominal  section  adhesions  are  always  formed. 
These  may  fix  the  bowel  in  such  a  way  as  to  kink  it, 
and  so  obstruct  the  passage  of  its  contents.  At 
present  we  know 
not  how  to  prevent 
this.  Intra-perito- 
neal  adhesions  are 
in  time  absorbed. 

Porro's  opera- 
tion.— Porro's  mo- 
dification of  Caesar- 
ian section  was 
introduced  at  a 
time  (1876)  when 
the  mortality  of 
Caesarian  section 
was  just  beginning 
to  be  reduced  below 

80  per  cent.  This  large  mortality  had  been  partly 
because  operators  then  knew  not  how  to  suture  the  uter- 
ine wound,  so  that  the  wound  often  gaped,  and  either 
haemorrhage  or,  later  on,  lochia  escaped  into  the  perito- 
neal cavity,  and  peritonitis  followed ;  and  partly  from 
want  of  antisepsis.  Porro,  instead  of  imperfectly  sutur- 
ing the  uterine  wound,  secured  the  cervix  in  the  lower 
angle  of  the  abdominal  wound  with  a  clamp,  and  then 
cut  away  the  body  of  the  uterus.  This  did  away  with 
the  danger  of  haemorrhage  and  escape  of  lochia  into  the 
peritoneal  cavity,  and  thus  at  the  time  was  an  improve- 
ment, bringing  down  the  mortality  after  delivery  by 
Caesarian  section  to  between  40  and  50  per  cent. 

The  objections  to  it  are  (1)  that  the  part  beyond 
the  clamp  is  killed  and  has  to  slough  off,  and  it  is 
difficult  to  keep  a  part  aseptic  while  a  dead  slough 


Fig.  160.— Mode  of  Stitching  Cervical  Stump. 


422  Difficult  Labour. 

is  being  separated  ;  (2)  that  convalescence  is  uncom- 
fortable, because  the  pressure  of  the  clamp,  and  the 
necessary  dressings,  are  painful ;  and  it  is  slow,  because 
the  surface  has  to  heal  by  granulation  after  the  slough 
has  separated ;  (3)  that  the  lips  of  the  abdominal 
incision,  being  separated  by  the  interposed  cervix, 
cannot  be  perfectly  united,  but  a  gap  is  left,  through 
■which  a  hernia  is  apt  afterwards  to  protrude.  For 
these  reasons  sui'geons  no  longer  clamp  the  cervix  in 
the  lower  angle  of  the  wound,  unless  it  be  for  some 
very  exceptional  reason.  The  one  advantage  of 
Porro's  operation  is  that  it  is  easier.  It  is  now  only 
an  emergency  operation,  to  be  done  (with  self- 
reproach)  when  the  need  for  delivery  is  urgent,  de- 
livery by  the  natural  passage  impossible,  and  the 
operator,  either  from  want  of  knowledge,  experience, 
instruments,  light,  assistance,  or  other  condition  neces- 
sary for  success,  thinks  himself  unable  to  deal  with  the 
uterus  by  an  intra-peritoneal  method.  Therefore  it  is 
one  which  ought  seldom  to  be  done,  and  ought  soon 
to  become  obsolete.  I  shall  describe  the  simplest  way 
of  doing  it,  which  is  that  devised  by  Lawson  Tait. 

Mode  Of  Operation. — The  instruments  needed 
are  as  for  Caesarian  section,  with  the  addition  of  a 
piece  of  indiarubber  drainage-tube,  about  2  feet  long, 
and  two  or  three  knitting  needles.  The  preliminaries 
are  the  same,  and  the  opening  of  the  abdomen  is  done 
in  the  same  way.  Then  with  the  hand  put  the  piece 
of  tubing  as  a  loop  over  the  fundus  uteri,  and  bring  it 
down  so  as  to  encircle  the  cervix,  taking  care  to  keep 
it  close  to  the  uterus  in  doing  so,  that  a  loop  of  intes- 
tine may  not  bo  included.  Tie  the  ends  of  the  tube  in 
a  single  hitch,  pull  it  tight  round  the  cervix,  and 
either  give  the  ends  to  an  assistant  to  hold,  or  grasp 
the  hitch  with  a  pair  of  artery  forceps.  This  will 
stop  the  circulation  through  the  uterus.  The  reason 
for  tying  a  single  hitch  only  is  that  should  it  prove, 
when  you  cut  into  the  uterus,  that  the  ligature  is  not 
tight  enough,  it  can  be  pulled  tighter  immediately. 
Now  incise  the  uterus.     Make  an  incision  about  an 


Porro's   Operation.  423 

inch  long  at  the  lower  part  of  the  body  of  the  uterus ; 
put  your  finger  in  it,  and  extend  the  opening  upwards 
by  tearing.  By  tearing  you  diminish  the  risk  of 
cutting  the  foetus,  and  also  that  of  haemorrhage  in  case 
your  ligature  is  not  tight  enough.  Extract  the  child 
by  its  foot,  and  hand  it  to  an  assistant.  The  uterus 
will  now  be  smaller  in  bulk.  Pull  it  out  of  the 
abdomen,  if  your  assistant  has  not  expressed  it. 
Remove  the  placenta.  Tighten  the  knot,  if  it  requires 
tightening,  as,  owing  to  the  lesser  bulk  of  the  uterus, 
it  probably  will.  When  you  have  pulled  it  as  tight 
as  possible,  tie  a  second  hitch,  and  a  third  if  the 
second  seems  not  secure.  Now  push  two  knitting- 
needles  across  from  side  to  side,  through  the  flattened 
drainage-tube  and  through  the  cervix.  This  done, 
cut  the  uterus  off  about  three-quarters  of  an  inch 
above  the  knitting-needles.  Now  wash  out  the 
peritoneal  cavity,  if  you  think  any  foreign  matter  has 
got  into  it,  with  clean  warm  water,  pouring  it  in  from 
a  jug,  and  pressing  it  out  again  until  it  comes  back 
clean.  Leave  in  it  the  water  that  you  cannot  easily 
press  out.  Now  sew  up  the  abdominal  wound  as  in 
Caesarian  section,  except  that  the  lowest  stitch  should 
pass  through  the  stump,  about  a  quarter  or  half  an 
inch  (according  to  the  thickness  of  the  abdominal 
wall)  below  the  elastic  ligature,  as  well  as  through  the 
abdominal  wall,  so  that  it  may  keep  the  abdominal 
wall  closely  applied  to  the  stump.  Having  closed 
the  abdomen,  the  main  point  i3  to  keep  the  stump 
dry  and  clean  ;  dress  the  stump  by  thickly  powdering  it 
with  equal  parts  of  iodoform  and  tannic  acid.  The  tannic 
acid  will  tan  the  dead  tissue,  and  the  iodoform  will  keep 
it  sweet.  Place  Gamgee  tissue  over  the  line  of  incision 
and  around  and  over  the  stump,  and  a  binder  over 
all.  The  stump  should  be  dressed  daily,  the  Gamgee 
tissue  changed,  the  stump  and  the  skin  round  it  dried 
with  cotton  wool,  and  liberally  powdered  with  the 
iodoform-tannin  powder.  The  part  of  the  stump 
beyond  the  ligature  will  be  separated  in  about  ten  or 
twelve  days. 


424 
CHAPTER  XXIX. 

SYMPHYSIOTOMY. 

In  the  foregoing  chapter  the  comparison  has  been 
made  between  C»sarian  section,  with  good  prospect 
of  a  living  child ;  and  craniotomy,  which  is  safer  for 
the  mother  but  fatal  to  the  child. 

But  lately  an  old  method  of  treatment  has  been 
re-introduced,  which  seems  to  combine  safety  both  for 
mother  and  child,  in  some  cases  in  which  Caesarian 
section  was  formerly  relatively  indicated.  This  treat- 
ment is  symphysiotomy.  Further  experience  is  re- 
quired before  the  place  of  this  operation  among  our 
resources  can  be  settled. 

This  operation  was  devised  by  Sigault  more  than  a 
century  ago.  At  that  time  antiseptics  were  unknown, 
and  therefore  either  the  patients  died  or  else  the 
parts  did  not  heal  properly,  and  the  results  were  bad. 

Lately  the  operation  has  been  revived — first  in 
Italy,  then  in  France.*  It  has  been  done  with 
antiseptic  care,  and  it  has  been  proved  that  by  it 
children  can  be  delivered  alive  through  pelves  so 
small  that  otherwise  craniotomy  would  have  been 
required.  Its  mortality  is  small,  and  when  proper 
care  is  used,  union  of  the  divided  parts  takes  place 
without  any  bad  symptoms. 

This  operation  does  not  interfere  with  fertility. 
Hence  it  might  be  required  time  after  time  in  the 
same  patient.  "We  know  not  yet  whether  symphysi- 
otomy can  easily  and  safely  be  repeated  many  times 
in  the  same  patient :  but  I  know  of  no  reason  to  the 
contrary.  After  the  symphysis  has  been  divided  the 
two  pubic  bones  unite  by  fibrous  tissue.  It  has  been 
found  that  even  when  by  this  fibrous  union  the  bones 
are  not  in  close  contact,  yet  the  patients  ultimately 
become    able  to  stand,   walk,   and   do    the   ordinary 

*  See  Aiinales  de  Gynecologic,  1893. 


SVMPHYS/O  TO  MY. 


425 


business  of  their  lives  without  difficulty.  Cases  have 
occurred  in  which  after  symphysiotomy  the  pelvis  has 
remained  so  enlarged  that  the  patients  have  had  other 
children  without  operative  aid,  and  have  considered 
themselves  well.  The  only  real  danger  that  attends 
symphysiotomy  arises  from  its  performance  in  unsuit- 
able cases :  those  in  which  the  child  is  too  large,  in 
relation  to  the  pelvis,  to  be  delivered  by  symphysi- 


Fig.   161.— Diagram  showing  Change  in  Size  of  Pelvis  effected  by  Sym- 
physiotomy.   {From  a  Drawing  to  Scale  by  Roux  and  Seynes.) 

Sacro-iliac  sychondroses ;  s,  sacral  promontory ;  p,  pubes ;  thick  line,  con- 
tracted pelvis ;  dotted  line  a.  v",  pelvis  as  enlarged  by  symphysiotomy  ; 
circles  (thin  lines),  size  ,  of  bead  that  can  pass  through  pelvis -before  and 
after  symphysiotomy. 

otomy.  In  such  cases  there  is  danger  of  too  wide 
separation  of  the  pubic  bones,  leading  to  laceration 
of  the  urethra,  base  of  bladder,  or  adjacent  parts,  and 
entailing  permanent  incontinence  of  urine.  Such 
excessive  separation  may  also  injure  the  sacro-iliac 
synchondrosis,  and  thus  lead  to  long-standing  lame- 
ness.    Hence  be  sure,  before  doing  symphysiotomy, 


426  Difficult  Labour 

that  af  oer  it  the  child  can  be  easily  delivered :  and  if 
this  is  doubtful,  choose  Caesarian  section  or  craniotomy. 
Indications. — By  symphysiotomy  about  half  an 
inch  is  practically  added  to  the  conjugate  diameter  of 
the  brim.  The  two  pubic  bones  can  be  separated  about 
two  inches  (Fig.  161).    Now  as  upon  the  average  a  con- 
jugate of  three  inches  and  a  quarter  in  a  flat  pelvis  is 
the  smallest  size  that  will  allow  a  full-time  child  to  pass, 
it  follows  that  a  flat  pelvis  having  a  conjugate  of  two 
inches  and  three  quarters  is  about  the  smallest  pelvis 
in  which  it  is  advantageous  to  perform  symphy- 
siotomy.    It  is  true  that  sometimes  a  living 
full-term  child  is  so  small  or  its  head  is  so  soft 
that  it  will  pass  through  a  pelvis  having  a 
conjugate  of  only  three  inches  ;  but  we  cannot 
count   upon   this.     With   a  pelvis   having  a 
conjugate   larger    than    three   inches    and    a 
quarter,  symphysiotomy  may  be  done  if  when 
the  os  uteri  is  fully  dilated  the  head  will  not 
enter  the  brim,  and  cannot  be  pulled  into  it 
with  forceps;  if  the  reason  of  this  is  not  a 
malposition  which  can  be  detected,  but  simply 
the  size  and  hardness  of  the  head,  and  if  the 
equator  of  the  head  exceeds  the  diameter  en- 
Fig.  162.    gaged  in  the  brim  by  less  than  half  an  inch. 

Kni°fe°for  Mode  of  performance.— The  time  for  its 
Sfotony  performance  is  when  the  os  is  dilated  enough 
for  immediate  delivery.  The  patient  is  put  in 
the  lithotomy  position,  and  the  mons  Veneris,  labia, 
and  adjacent  parts  washed  and  shaved.  Shaving  is 
necessary  if  strapping  is  to  be  employed.  If  the 
patient  will  be  so  well  looked  after  that  strapping 
need  not  be  used,  shaving  the  vulva  is  not  required. 

The  only  instrument  required  is  a  sharp-pointed 
tenotomy  knife  (Fig.  162).  The  one  I  have  used  has 
a  cutting  edge  seven-eighths  of  an  inch  long  by  one- 
eighth  broad.  Have  ready  about  eight  feet  of  strong 
adhesive  strapping,  two  inches  wide,  and  a  strong 
binder  or  belt  of  unyielding  material.  The  strappings 
should  be  cut  ready  into  four  strips,  each  at  least  two 


SYMPH  YS10  TO  MY.  427 

feet  long ;  two  of  the  strips  should  be  cut  narrow  in 
the  centre,  and  the  other  two  have  a  strip  cut  out  in 
the  centre,  thus  (Fig.  163). 


i r 


Fig.  163.— Strapping  to  draw  together  Parts  after  Symphysiotomy. 

Strips  a  and  b  are  applied  on  opposite  sides ; 
strip  A  is  passed  through  b,  and  thus  they  can  be 
pulled  tight. 

An  assistant  is  wanted  to  anaesthetise  the  patient ; 
and  the  help  of  another  is  advantageous,  but  is  not 
necessary  if  there  is  a  good  nurse. 

Ascertain  accurately  the  position  of  the  child ; 
and  if  it  is  lying  with  its  abdomen  forwards,  by 
bimanual  external  manipulation  turn  its  back  to  the 
front. 

Take  the  tenotomy  knife,  and  press  its  point 
through  the  skin  opposite  the  middle  of  the  symphysis 
pubis.  It  will  easily  penetrate  the  symphysis. 
Jf  you  have  not  hit  the  middle  line,  and  the  point 
of  the  knife  impinges  on  bone,  the  difference  of 
resistance  will  inform  you  of  the  fact.  If  so,  shift 
the  point  a  little  to  the  right  or  left,  and  it  will  come 
upon  the  symphysis.  When  the  knife  has  penetrated 
the  symphysis,  cut  downwards  until  you  have  reached 
and  divided  the  ligamentum  arcuatum.  Then  turn 
the  blade  so  that  the  cutting  edge  is  upwards,  and 
divide  the  rest  of  the  symphysis.  There  may  be  a 
little  difficulty  in  dividing  the  last  ligamentous  fibres 
at  the  top  and  lower  part  of  the  symphysis,  because 
there  is  a  little  tendency  for  the  knife  to  push  these 
fibres  before  it,  instead  of  cutting  quickly  through 
them.     You  will  overcome  this  tendency  by  pressing 


428  Difficult  Labour. 

with  the  finger  applied  externally  these  fibres  against 
the  knife.  When  you  have  divided  all  the  structures 
which  unite  the  two  pubic  bones,  they  will  at  once 
spring  about  half  an  inch  apart.  Then  seize  the  foetal 
head  with  forceps,  and  deliver. 

Having  delivered  the  child,  let  your  assistants 
press  together  the  two  pubic  bones,  and  then  apply 
the  strapping,  two  pieces  on  each  side,  crossing,  as 
explained  above,  and  pulled  as  tight  as  possible. 
Having  made  the  strapping  fast,  try  to  keep  the  bones 
still  more  securely  together  by  putting  on  the  belt  or 
binder  as  tightly  as  possible.  The  two  sides  of  the 
pelvis  can  be  kept  firmly  together  by  an  unyielding 
binder,  without  strapping.  You  may  trust  to  this  if 
the  patient  is  under  the  charge  of  a  careful  nurse, 
who  will  see  to  the  prompt  readjustment  of  the 
binder  should  it  slip  or  get  loose.  The  strapping 
gives  additional  security :  and  the  only  objections  to 
its  use  are  that  it  makes  dirty  marks  on  the  skin,  and 
that  pulling  it  off  is  disagreeable.  As  it  is  liable  to 
get  soiled,  it  may  have  to  be  changed  frequently. 

While  this  is  being  done,  watch  the  expulsion  of 
the  placenta,  and  the  retraction  and  contraction  of 
the  uterus. 

The  subsequent  management  of  the  case  is  simply 
that  of  an  ordinary  confinement,  with  the  addition  of 
care  to  keep  the  two  sides  of  the  pelvis  firmly  to- 
gether. 

The  mortality  of  this  operation,  if  performed  only 
in  suitable  cases,  and  according  to  the  subcutaneous 
method  here  described,  should  be  nil.  I  have  already 
pointed  out  the  conditions  under  which  the  operation 
becomes  dangerous. 


429 


CHAPTER  XXX. 

THE  INDUCTION  OF  PREMATURE  LABOUR. 

By  this  term  is  meant  the  induction  of  labour  after 
the  child  is  viable :  that  is,  after  the  twenty-eighth 
week,  but  before  the  full  term  of  pregnancy  has 
expired.  When  we  empty  the  uterus  before  the 
child  is  viable,  we  call  it  " abortion"  not  " premature 
labour." 

Indications  for  the  induction  of  labour 
prematurely. — These  may  be  divided  into  five 
groups : — 

1.  Contraction  of  the  pelvis. — In  chapters  xiv.  and 
xvi.  the  diagnosis  of  this  condition  has  been  described 
and  the  time  defined  at  which  labour  should  be 
brought  on. 

2.  Tumours  of  the  pelvis  contracting  its  cavity. — 
Information  as  to  these  rare  cases  will  be  found  in 
chapter  xix. 

3.  Excessive  size  of  the  child. — Sometimes  it  is 
found  that  a  woman  will  in  pregnancy  after  pregnancy 
produce  a  child  so  large  that  it  cannot  be  born  alive, 
even  though  the  pelvis  be  not  contracted.  We  do  not 
know  the  conditions  upon  which  the  size  of  the  child 
depends  exactly  enough  to  be  able  to  predict  early  in 
pregnancy  whether  it  will  be  large  or  small.  But  if  a 
patient  has  had  a  child  born  dead  because  it  was  too 
big,  we  can  prevent  this  in  another  pregnancy  by 
bringing  on  labour  prematurely.  In  such  a  case, 
advise  the  patient  if  she  finds  herself  pregnant  again 
to  come  to  you  for  examination  once  a  fortnight 
during  the  last  two  months  of  pregnancy.  At  each 
visit  observe  the  size  of  the  uterus.  Feel  the  foetal 
head  with  your  hands  on  the  abdomen,  and  try 
how  easily  you  can  press  it  down  into  the  pelvis. 
The  measurement  from  the  symphysis  pubis  to  the 


43°  Difficult  Labour. 

top  of  the  uterus  over  its  convexity  averages  at 
full  term  13  inches :  the  greatest  girth  of  the 
abdomen  is  usually  under  36  inches.  If,  before  the 
patient  thinks  she  has  reached  term,  you  find  these 
measurements  exceeded  (the  patient  not  being  fat  or 
dropsical) ;  or  if  you  find  that  the  head,  when  you 
press  it  down  into  the  brim,  seems  quite  to  fill  it, 
induce  labour  without  waiting  for  the  calculated  time 
to  arrive.  When  the  patient  is  lying  on  her  back 
you  may  sometimes  find  difficulty  in  pressing  the  head 
into  the  brim,  owing  to  the  fact  that  the  axis  of  the 
uterus  is  not  a  continuation  of  the  axis  of  the  pelvic 
brim,  but  lies  behind  it.  When  this  is  so,  if  you 
prop  the  patient  with  pillows,  etc.,  into  a  semi- recum- 
bent position,  so  as  to  make  the  axis  of  the  uterus 
vertical  to  the  plane  of  the  brim,  you  will  find  the 
head  can  then  easily  be  pressed  into  the  brim,  and 
may  even  sink  into  it  by  gravity. 

4.  Intro-uterine  death  of  the  foetus.  —  Certain 
diseases  lead  to  intra-uterine  death  of  the  child.  The 
only  ones  that  have  been  proved  to  do  this  are  : 
syphilis,  ancemia,  cancer,  and  Bright 's  disease.  Thero 
are  other  conditions  which  do  it,  but  our  knowledge  of 
them  is  not  at  present  definite.  If  the  child  dies 
in  utero,  you  can  judge  from  its  size  of  the  date  at 
which  death  took  place.  If  it  happens  more  than  once 
that  a  patient's  child  has  died  in  utero  shortly  before 
delivery  at  term,  and  you  cannot  find  out  the  cause, 
you  will  do  well,  in  order  to  prevent  the  recurrence  of 
this  calamity,  to  induce  labour  shortly  before  the  date 
at  which  in  former  pregnancies  intra-uterine  death 
took  place.  If  you  can  find  out  the  cause  of  death, 
and  so  treat  it  as  to  prevent  intra-uterine  death,  that 
will  be  better  still. 

5.  Disease  of  the  mother,  dependent  upon  preg- 
nancy, or  aggravated  by  it,  and  threatening  the 
mother's  life.  This  group  it  is  only  proper  to  mention 
here,  for  description  of  these  diseases  is  out  of  place 
in  a  work  on  difficult  labour.  Refer  to  works  which 
treat  of  the  diseases  of  pregnancy.   • 


Rupture   of  Membranes.  431 

Methods. — Many  ways  of  inducing  labour  have 
been  recommended. 

The  effective  methods  may  be  broadly  classified  as 
four : — 

1.  Separation  of  the  membranes. 

2.  Irritation  of  the  cervix,  to  produce  reflex  con- 

traction of  the  uterus. 

3.  Rupture  of  membranes. 

4.  Dilatation  of  the  cervix. 

Galvanism  is  useless.  Ergot  and  some  other  drugs 
have  been  recommended.  Ergot  hastens  labour  that 
has  already  begun,  but  it  will  seldom  start  it.  No 
other  drug  has  been  demonstrated  to  have  any  effect. 

The  choice  of  method  depends  upon  the  reason  for 
inducing  labour. 

Rupture  of  membranes. — The  simplest  method 
is  the  rupture  of  the  membranes,  thereby  letting  the  • 
waters  escape.  "When  this  is  done,  uterine  action 
follows,  and  the  other  uterine  contents  are  soon 
expelled.  The  membranes  can  be  broken  with  an 
ordinary  uterine  sound. 

The  objection  to  this  method  is  that  it  robs  us  of 
the  natural  dilator  of  the  cervix.  Labour  thus  induced 
is  attended  with  the  disadvantages  that  come  from 
premature  rupture  of  the  membranes.  Hence,  when 
labour  is  induced,  not  because  the  condition  of  the 
mother  demands  speedy  relief  from  her  pregnancy, 
but,  as  in  cases  of  contracted  pelvis,  in  order  that  the 
child  may  be  born  alive,  this  method  is  unsuitable. 
But  when  labour  is  induced  because  the  increased 
tension  within  the  belly  is  aggravating  some  disease 
from  which  the  mother  is  suffering ;  or  because  there 
is  bleeding  from  the  placental  site,  and  it  is  im- 
perative that  the  uterus  should  quickly  contract ; 
then,  rupture  of  the  membranes  is  the  quickest  and 
surest  way  of  giving  partial  relief  immediately,  and 
complete  relief  speedily ;  and  this  advantage,  in  such 
cases,  outweighs  the  disadvantages.  Rupture  of 
membranes  is  the  method  when  it  is  necessary  to 
lessen  the  size  of  the  uterus  quickly. 


432  Difficult  Labour. 

In  cases  in  which  there  is  no  need  for  hurry,  it  is 
better  to  use  a  method  which  retains  for  us  the 
dilating  bag  of  membranes. 

Irritation  Of  the  cervix,  in  order  to  provoke 
reflex  contraction  of  the  body,  has  been  used.  Two 
ways  have  been  practised  :  one  is  packing  the  vagina 
either  with  plugs  of  soft  material  such  as  lint  or  wool, 
or  with  a  dilating  bag.  This  is  a  very  uncertain  way, 
and  very  disagreeable  to  the  patient ;  therefore  I 
advise  against  it.  The  other  is  known  by  Kiwisch's 
name,  and  consists  in  the  use  of  a  hot  vaginal  douche. 
The  effect  of  this  is  sometimes  to  provoke  reflex 
uterine  contractions,  and  thus  to  start  labour.  The 
douche  should  be  used  three  or  four  times  a  day,  for 
five  or  ten  minutes  at  a  time.  No  poisonous  antiseptic 
should  be  used,  lest  absorption  should  take  place.  The 
water  should  be  at  the  temperature  of  110°  F.  The 
douche  is  better  given  with  a  douche- tin  than 
with  a  syringe,  for  with  this  instrument  there  is  no 
danger  of  harm  from  too  forcible  injection  of  the 
stream  of  water. 

This  mode  of  inducing  labour  is  harmless,  if  the 
precautions  above  mentioned  are  observed.  It  is 
cleanly,  and  not  disagreeable  to  the  patient.  The 
objection  to  it  is  that  it  is  always  slow,  and  often 
ineffectual.     There  are  better  ways. 

Separation  of  the  membranes. — A  more  sure 

way,  and  for  most  cases  the  best  way,  is  the  separa- 
tion of  the  membranes  from  the  uterus.  This  acts  by 
letting  the  bag  of  membranes  advance  into  the  os 
uteri  and  dilate  it.  A  small  artificial  separation  of 
the  membranes  will  generally  start  labour  within 
about  twenty-four  hours. 

There  are  several  ways  of  separating  the  mem- 
branes. The  best  are  :  (a)  with  the  finger,  (b)  with  a 
bougie.  If  the  os  uteri  will  admit  your  finger,  intro- 
duce it,  and  move  it  round  the  lower  segment  of  the 
uterus,  separating  the  membranes  as  far  as  you  can 
reach.  The  usual  effect  of  this  is  that  the  advance  of. 
the  bag  of  waters  into  the  os  is  so  helped  that  it  soon 


Separation  of  Membranes.  433 

bulges  into  the  os,  and  provokes  reflex  uterine  con- 
tractions. 

This  method  is  not  often  practicable,  because  the 
os  uteri  is  not  often  at  seven  months'  pregnancy  large 
enough  to  admit  the  finger.  If  it  be  not,  use  a  bougie, 
not  a  catheter,  because  it  is  difficult  to  be  sure  that  the 
inside  of  a  catheter  is  clean.  This  is  known  as  Krause's 
method.  Boil  the  bougie,  and  use  it  when  cooled 
enough  to  be  neither  too  hard  nor  too  soft  Take  a 
No.  10  bougie  in  your  right  hand.  Put  the  patient  on 
her  left  side,  and  pass  two  fingers  up  to  the  cervix ; 
guided  by  these  fingers,  pass  the  bougie  into  the  os 
uteri,  and  push  it  up  slowly  as  far  it  will  go.  When 
the  tip  is  within  the  vagina,  grasp  it  with  the  two 
vaginal  fingers,  and  press  it  up  till  the  end  lies  in  the 
external  os.  Then  press  the  cervix  backwards.  The 
pressure  of  the  posterior  vaginal  wall  will  keep  the 
bougie  in  place;  there  is  no  need  for  any  tying  or 
plugging.  In  passing  a  flexible  bougie  into  the  uterus 
like  this,  it  is  unimportant  whether  it  lies  along  the 
anterior  or  posterior  wall  of  the  uterus  or  along  one 
side ;  you  cannot  guide  it  along  either  side  of  the 
uterus,  nor  can  you  tell  at  what  part  of  the  uterus  it 
lies.  Leave  the  bougie  in  the  uterus  until  labour 
comes  on.  If  labour  pains  have  not  begun  at  the  end 
of  twenty-four  hours,  you  may  conclude  that  the 
method  is  in  the  case  in  question  a  failure. 

In  this  mode  of  inducing  labour,  not  only  are  the 
membranes  separated,  but  a  foreign  body  is  left  in  the 
uterus,  and  this  aids  the  effect  of  separation  of  the 
membranes.  Other  modes  of  separating  the  mem- 
branes have  been  proposed,  such  as  the  injection  of 
a  large  quantity  of  water  between  the  membranes  of 
the  uterus.  This  is  dangerous.  A  small  quantity  of 
glycerine  has  been  used  for  the  same  purpose.  This 
has  no  advantage  over  the  bougie,  and  is  more 
troublesome. 

When  labour  has  been  induced  by  separating  the 
membranes,  either  by  finger  or  bougie,  it  more 
resembles  a  natural  labour  at  term  than  the  labour 
cc— 36 


434  Difficult  Labour. 

induced  in  any  other  way,  except  by  the  vaginal 
douche.  The  bag  of  membranes  advances  into  the 
os  and  dilates  it.  The  labour  should  be  managed  just 
like  one  at  term.  You  should  only  interfei'e  when 
conditions  arise  which  would  call  for  interference  in 
any  labour. 

This  method  is  more  sure  in  its  effect  than 
Kiwisch's  method,  and  is  therefore  to  be  preferred  to 
it.  The  disadvantages  which  are  attributed  to  it  are 
(1)  the  possibility  of  septic  infection  by  the  bougie. 
This  is  to  be  prevented  by  antiseptic  care.  Immerse 
the  bougie  in  sublimate  glycerine  before  putting  it  in, 
and  after  putting  it  in  give  a  vaginal  sublimate 
douche.  (2)  The  possibility  of  rupture  of  the  mem- 
branes. The  membranes  often  do  rupture  too  soon 
in  premature  labour,  but  this  is  because  their  early 
rupture  is  favoured  by  the  conditions — contracted 
pelvis,  etc. — for  which  premature  labour  is  often 
induced.  But  sometimes  it  seems  as  if  the  rupture 
of  the  membranes  was  done  by  the  passage  up  of  the 
bougie.  The  way  to  avoid  this  is  by  passing  up  the 
bougie  very  slowly  and  gently.  (3)  It  is  said  that 
with  the  bougie  you  may  wound  the  placenta  or 
separate  part  of  it.  This  is  to  be  avoided  by  gentle- 
ness. If  you  pass  the  bougie  up  slowly,  it  will  take 
the  path  of  least  resistance,  and  find  its  way  round 
the  placenta.  As  it  is  not  often  possible  before  delivery 
to  find  out  where  the  placenta  is,  you  cannot  prevent 
injury  to  it  in  any  other  way  than  by  gentleness.  If 
you  use  a  catheter  with  a  stilette  in  it,  or  pass  up  a 
syringe  to  inject  glycerine,  you  will  be  more  likely  to 
rapture  the  membranes  or  wound  the  placenta  than  if 
you  use  a  flexible  bougie. 

The  objections  above-named  are  accidents  so  far 
preventible  that  they  occur  very  rarely,  and  are  not 
of  much  practical  importance.  The  one  real  objection 
to  this  method  is  that  it  is  uncertain.  Usually,  pains 
come  on  after  the  bougie  has  been  in  the  uterus 
about  twelve  hours.  But  sometimes  a  bougie  will 
stay  in  the  uterus  for  days  without  provoking  any 


1 
Dilatation  of   Cervix.  435 

uterine  contraction.  We  do  not  know  why  it  is 
that  in  some  patients  labour  is  easily  started,  while 
others  will  tolerate  much  interference  without  the 
ovum  being  expelled.  If  the  bougie  is  used  properly, 
no  harm  will  result  even  should  it  fail,  beyond  the 
postponement  for  twenty-four  hours,  which  is  not  a 
great  matter.  You  may,  if  you  like,  combine  the 
bougie  with  Kiwisch's  method ;  but  I  have  not  found 
that  when  the  bougie  failed  to  excite  uterine  action, 
the  combination  of  the  douche  with  it  succeeded. 
Dilatation   of    the    cervix.— If   the  above 

described  methods  of  inducing  labour  fail,  you  are 
reduced  to  choose  between  two  plans,  (a)  rupture  of 
the  membranes,  and  (6)  artificial  dilatation  of  the 
cervix.  I  have  stated  above  in  what  cases  I  think 
that  rupture  of  the  membranes  should  be  chosen :  I 
refer  to  it  again  here,  to  say  that  in  no  other  cases 
but  those  requiring  haste  should  labour  be  induced 
by  rupturing  the  membranes ;  artificial  dilatation  of 
the  cervix  is  much  preferable. 

In  most  cases,  in  almost  all  first  pregnancies,  you 
will  find  that  the  cervical  canal  will  not  admit  a 
finger.  In  that  case  begin  the  dilatation  with  a  piece 
of  laminaria.  Pull  the  cervix  down  with  a  blunt 
volsella.  Put  into  the  cervix  side  by  side  as  many 
pieces  as  you  can  get  into  it,  taking  care  they  go 
well  past  the  internal  os.  The  number  will  depend 
upon  the  size  of  the  pieces  and  the  size  of  the  canal. 
Remove  the  volsella  and  push  the  cervix  well  back, 
that  the  pressure  of  the  posterior  vaginal  wall  on 
the  os  externum  may  keep  them  in.  Before  you  put 
in  each  piece,  immerse  it  in  sublimate  glycerine  (1  in 
2,000),  and  after  removing  them  use  a  sublimate 
(1  in  2,000)  vaginal  douche  before  beginning  any 
further  manipulation.  Take  the  tents  out  at  the  end 
of  twenty-four  hours.  Two  tents  of  medium  size  will 
have  dilated  the  cervical  canal  so  as  to  admit  the 
finger  easily.  Although  the  patient  may  have  had 
some  pain,  yet,  if  the  case  be  one  in  which  the  bougie 
has    failed,  if  you    take  out  the    laminaria   and    do 


436 


Difficult  Labour. 


nothing  more,  the  cervix  will  contract  again.     There 
fore  now  accelerate  the  dilatation  of  the  cervix. 


How  to  hasten  dilatation. — The  best  way  of 

accelerating   the  dilatation  of  the  cervix   is   by  the 


Champetier's  Bag.  437 

dilating  bag  of  Champetier  de  Ribes.  This  is  made 
of  waterproof  silk,  not  elastic,  so  that  it  will  hold 
about  seventeen  ounces  of  water  and  no  more.  Its 
shape  is  that  of  an  inverted  cone,  the  apex  of  the 
cone  lying  in  the  internal  os,  and  having  a  tube 
attached  to  it  so  that  water  can  be  pumped  into  it. 
When  full  the  base  of  the  cone  measures  about 
three  inches  and  a  half  across,  so  that  when  it  can 
pass  out  the  os  uteri  is  so  dilated  that  you  can  deliver 
immediately.  You  can  put  in  the  bag  when  the  os 
uteri  is  open  enough  to  admit  two  fingers,  not  before. 
A  pair  of  forceps  is  sold  with  it.  Having  first  boiled 
the  bag  and  then  washed  it  well  with  1  in  1,000 
sublimate  solution,  fold  it  longitudinally  as  small  as 
you  can,  and  grasp  it  with  the  forceps  (Fig.  1G1). 
Lubricate  liberally  with  sublimate  glycerine  the  bag 
held  by  the  forceps  and  pass  it  into  the  uterus. 
When  the  whole  of  the  bag  is  within  the  uterine 
cavity,  disarticulate  the  forceps  and  remove  each  blade 
separately.  Then  with  an  ordinary  syringe  slowly 
pump  water  into  the  bag  until  no  more  can  be  got  in 
(Fig.  165).  Then  turn  the  tap,  and  leave  the  bag  in 
the  uterus.  When  the  dilatation  is  complete  the  bag 
will  be  expelled  from  the.  uterus  and  afterwards  from 
the  vagina.  If  pains  are  infrequent  and  feeble,  you 
can  hasten  dilatation  by  pulling  on  the  bag. 

As  the  bag  measures  three  inches  and  a  half  in 
diameter  at  the  base,  if  it  is  used  in  a  contracted 
pelvis  having  a  conjugate  less  than  this,  when  the 
bag  is  fully  expanded  it  may  be  held  in  the  uterus  by 
the  bony  contraction  after  full  dilatation  of  the  cervix. 
If  two  ounces  of  fluid  are  let  run  out  of  the  bag  after 
it  has  been  filled,  it  can  then  easily  be  compressed  till 
its  diameter  measures  only  two  inches  and  a  half.  If 
you  let  more  than  this  escape  the  bag  becomes  shape- 
less. Therefore,  in  using  Ohampetier's  bag  for  a  case 
in  which  the  pelvis  measures  less  than  three  inches 
and  a  half  in  its  smallest  diameter,  first  fill  the  bag, 
and  then  let  two  ounces  of  water  run  out. 

Ohampetier's  bag  has  these  advantages  over  the 


438  Difficult  Labour. 

hitherto  well-known  Barnes's  bags :  (f)  that  it  is 
more  easily  put  in.  (2)  The  bag  when  once  in  its 
place  dilates  the  cervix  to  the  full  extent.  You  have 
not  the  trouble,  nor  the  patient  the  suffering,  caused 
by  putting  in  bag  after  bag.  (3)  It  does  not  alter  its 
shape,  and  expand  unequally  under  pressure,  like 
a  bag  made  of  indiarubber.  It  is  urged  as  an 
objection  against  its  use  that  it  displaces  the  head. 
So  it  does  :  so  does  Barnes's  instrument.  But  Cham- 
petier's  bag  dilates  the  cervix  so  completely  that  after 
it  has  done  its  work  you  can  deliver  at  once  by  turning, 
and  therefore  the  displacement  of  the  head  is  un- 
important. It  has  also  been  said  that  there  is  danger 
of  rupture  of  the  uterus,  but  Champetier's  bag  has 
now  been  very  largely  used,  and  no  case  has  been 
recorded  in  which  either  this  or  any  other  bad  effect 
has  been  produced  by  it. 

Contraction  without  retraction.  —  Champe- 
tier's bag  when  in  the  uterus  will  dilate  the  cervix 
and  provoke  uterine  contractions :  but  uterine  re- 
traction may  be  for  a  time  absent.  This  I  have  seen 
in  premature  labour  ;  and  cases  that  I  think  must 
have  been  of  the  same  kind  have  been  related  to  me 
by  others.  After  the  bag.  has  widely  dilated  the 
passages,  so  that  gentle  pulling  easily  withdraws 
it,  although  the  child  is  small,  and  the  uterus  con- 
tracts regularly,  and  there"  is  no  mechanical  obstacle 
to  delivery,  yet  the  child  does  not  advance.  Time  is 
the  only  treatment.  Do  not  deliver  :  if  you  do  there 
will  be  great  danger  of  post-partum  hemorrhage 
Wait,  and  in  time  the  uterus  will  begin  to  retract. 


439 


CHAPTER   XXXI. 

METHODS    OF    RAPID    DELIVERY. 

Methods  have  recently  been  introduced  by  which 
delivery  can  be  accomplished  by  the  vagina  much 
more  quickly  than  in  the  natural  way.     These  are  : — 

1.  Bossi's  dilator. — This  consists  of  four  blades 
which,  when  applied  to  one  another,  form  a  rod 
small  enough  to  enter  the  cervical  canal.  By  turning 
a  screw  these  can  be  separated,  so  that  the  cervix  is 
stretched  or  torn  open  till  its  canal  is  wide  enough  to 
let  the  child  pass.  With  strict  antisepsis,  immediate 
harmful  results  from  this  stretching  or  tearing  seem 
to  be  rare  :  at  least  they  are  little  heard  of. 

2.  Vaginal  Caesarian  section.— This  is  a  method 

of  rapid  delivery  introduced  by  Dr.  Diihrssen,  of 
Berlin.  Before  beginning  the  opei"ation  a  dose  of 
ergotin  is  injected.  If  the  vaginal  orifice  is  small 
the  operator  begins  by  making  an  incision  in  the 
lower  third  of  the  vagina  downwards  and  outwards 
on  one  or  both  sides,  deep  enough  to  considerably 
enlarge  the  lower  part  of  the  vagina.  Then  he  seizes, 
with  a  volsella,  the  posterior  part  of  the  cervix  uteri, 
and  puts  through  it  two  strong  traction  ligatures. 
He  pulls  the  cervix  down  with  these,  and  divides  it  in 
the  middle  line-up  to  the  insertion  of  the  vagina.  By 
this  incision  the  cellular  tissue  underneath  the 
peritoneum  is  reached.  The  peritoneum  is  then 
stripped  up  off  the  uterus  as  far  up  as  possible.  Then 
the  anterior  part  of  the  cervix  is  seized  and  pulled 
down  by  a  volsella.  The  anterior  vaginal  wall  is 
divided  close  to  the  cervix,  and  next  the  bladder  and 
ureters  are  stripped  off  the  uterus.  These  things 
having  been  done,  the  operator,  with  strong  scissors, 
rapidly  cuts  through  the  anterior  and  posterior  walls 


44°  Difficult  Labour. 

of  the  uterus  in  the  middle  line,  until  the  opening  made 
is  large  enough  to  admit  the  fist.  This  done,  the 
operator  may  either  insert  his  hand,  turn,  and 
deliver ;  or,  if  the  head  present,  he  may  extract  it 
with  forceps.  The  uterus,  being  under  the  influence 
of  ergotin,  will  contract  well,  and  expel  the  placenta. 
The  operator  then  pulls  the  cervix  down  to  the  vulva 
by  the  traction  ligatures,  and  proceeds  to  sew  up, 
with  a  continuous  catgut  suture,  fir^t  the  posterior, 
then  the  anterior,  incision  in  the  uterus.  At  the 
top  of  each  sutured  wound  a  slender  strip  of  gauze  is 
packed  in,  to  ensure  drainage  :  this  is  removed  at  the 
end  of  twenty-four  hours.  Lastly,  the  incision  by 
which  the  vaginal  orifice  was  enlarged  is  sewn  up. 
Dr.  Duhrssen  says  that  usually  within  five  minutes 
from  the  beginning  of  the  operation  he  has  the 
living  child  in  his  hand.  Up  to  the  time  of  writing 
his  last  paper  on  the  subject,  published  in  1904,  the 
operation  had  been  done  120  times,  with  18  deaths: 
a  mortality  of  15  per  cent.  This  is  much  too  high  to 
allow  me  to" recommend  the  operation. 

I  have  had  no  experience  of  either  of  these 
methods  of  rapid  delivery.  My  want  of  experience 
arises  from  the  fact  that  I  have  no  acquaintance  with 
cases  in  which  it  is  an  advantage  to  the  patient  to  be 
delivered  in  half  an  hour. 

Duhrssen  says  his  operation  is  indicated  in 
abnormal  conditions  of  the  cervix  which  render  its 
dilatation  by  the  natural  means  impossible  or  very 
difficult.  Among  these  he  specifies  cancer,  myomata, 
rigidity,  stenosis,  and  saccular  dilatation  of  the  lower 
uterine  segment.  If  from  cancer,  fibroids,  or  cicatricial 
tissue  the  cervix  uteri  is  so  hard,  or  its  canal  so 
obstructed,  that  dilatation  cannot  be  expected,  I  think 
that  abdominal  Caesarian  section  is  much  safer  than 
vaginal  Caesarian  section.  Rigidity  of  the  cervix  is 
generally  another  name  for  labour  rendered  slow  by 
weakness  of  pains.  Stenosis  is  excessively  rare  ;  and 
its  sufficient  treatment  is  to  dilate    the  os  till  the 


Methods  of  Rapid  Delivery.  441 

bag  of  membranes  can.  enter  it.  Saccular  dilata- 
tion of  the  lower  uterine  segment  is  a  condition 
which  uterine  action  will  always  overcome  if  time 
be  given  it. 

Next,  Diihrssen  says,  perilous  conditions  of  the 
mother  which  can  be  removed  or  rendered  less 
dangerous  by  emptying  the  uterus ;  viz.,  disease  of 
the  lungs,  heart,  or  kidneys.  I  know  no  such  disease 
that  requires  the  uterus  to  be  emptied  in  five  minutes. 
If  the  patient  is  in  such  a  state  that  restoration  to 
health  may  be  expected  from  terminating  the  preg- 
nancy, there  is  time  for  the  cervix  to  be  dilated  by 
gentle  means,  without  tearing  or  cutting.  Lastly  he 
mentions  cases  in  which  the  mother  is  about  to  die, 
and  I  suppose  the  operation  is  to  be  done  for  the 
sake  of  the  child.  In  such  a  case  I  should  prefer  the 
classical  Caesarian  section. 

Diihrssen  urges  his  operation  as  a  sort  of  specific 
for  puerperal  eclampsia  I  have  analysed  more  than 
two  thousand  cases  of  this  disease*  and  found  that 
delivery  neither  stops  the  fits  nor  improves  the  prog- 
nosis. Do  not,  therefore,  add  to  the  danger  of  this 
disease  either  by  vaginal  Caesarian  section  or  by  using 
Bossi's  dilator. 


*  Lancet,  1902,  Vol.  I. 


INDEX 


Abdominal  section  for  rupture  of 
uterus,  277 

Abnormal  uterine  action,  114 

Abortion,  429 

Acanthopelys,  260 

Accidental  haemorrhage,  292 

.  Turning  for,  381 

Accouchement  force,  315,  316,  317 

Achondroplasia,  212 

Adherent  placenta,  325 

prsevia  placenta,  312 

Adhesion  of  membranes  causing 
weak  pains,  119 

After-coming  head,  Delivery  of,  50 

.  with  flat  pelvis,  186 

Age,  influence  of,  on  labour,  250 

Ahlfeld  on  the  split  pelvis,  243 

Air,  Entrance  of,  Into  vein,  312 

Amnii,  liquor,  Excess  of,  causing 
malpresentations,  20 

Anaemia,  430 

after  placenta  prsevia,  312 

Anasarca,  Foetal,  105 

AnencephaluB,  108 

Anomalies  of  cord,  81 

of  pains,  114 

Ante-partum  hsemorrhage,  292 

Antipyrin  in  first  stage  of  labour, 
250 

Aorta,  Compression  of,  in  post- 
partum hsemorrhage,  341 

A  pplication  of  forceps,  368 

Arm,  Dorsal  displacement  of,  48, 
77,  79 

Arms,  Bringing  down  of,  46 

Ascites,  Foetal,  109 

Asymmetry,  Lateral,  158 

Atony  of  uterus,  332 

Atrophy  of  Whartonian  jelly,  81 

Axis  traction  forceps,  377 

Bag,  Water,  of  Champetier  de 
Ribes,  437 

Bandl's  ring,  129,  201,  267 

Barnes'  R.,  bags,  438 

■ ,  in  accidental  haemor- 
rhage, 300 

,    in    placenta    prsevia, 

316 

■ ,     on     forceps    in    occipito- 

posterior  positions,  10 

• ,  on  placenta  prsevia,  302,  317, 

318 


Barnes,  R.,  on  use  of  perchloride 

of  iron,  336 
Basilysis,  392 

Baudelocque,  Diameter  of,  170 
Belly  of  foetus,  Morbid   enlarge- 
ment of,  110 

,  Pendulous,  63, 149,  202 

, ,     causing     rupture    of 

vagina,  270 
Bipolar  version,  384 
Bistoury,  Use  of,  in  rigid  cervix, 

250,  252 
Bladder,  Distension  of  foetal,  109 
,    Fulness   of,    causing   weak 

pains,  119 
Blood,      Diseases      of,      causing 

hsemorrhage,  348 

,  Transfusion  of,  349 

vessels,  Diseases  of,  causing 

hsemorrhage,  348 
Blunt  hook,  The,  44 

to  axilla,  104 

Bones,  pelvic,  Tumours  of,  200 
Bossi's  dilator,  439 
Bougie.Useof,  to  induce  labour, 432 

, ,  in  smallness  ot  os,  251 

Brachial  plexus,  Injury  to,  60 
Braxton     Hicks     on'     obstructed 

labour,  125 
on  placenta  prsevia.  313, 

317 
on  "temporary  passive- 

ness,"  117 
Breech  delivery,  Injury  to  child  in, 

58 

forceps,  46 

presentations  in  small  round 

pelvis,  191 

■ ,  Management  of,  37 

Bregmato-cotyloid  position  of  head, 

3 
Bright's  disease,  430 
causing  hsemorrhage  into 

placenta,  296 
Broadbent,  Sir  "W.  H.,  on  displace- 
ment of  bladder,  120 
Brow  position  in  flat  pelvis,  205 

presentations,  26 

,   Moulding  of  head  in, 

33 
Burns  on  abnormalities  of  pains, 

114 
Button-hole  stitch,  416 


Index, 


443 


Caesarian  section,  409 

for  osteomalacic  pelvis, 

231 

in  cancer  of  cervix,  252 

in  flat  pelvis,  196 

in  kyphotic  pelvis,  225 

Uterine  rupture  after,  263 

,  Vbginal,  439 

Callipers,  Duncan's,  '£67 
Cameron  on  Csesarian  section,  418 
Cancer  causing  intra-uterine  death, 

430 

,  Haemorrhage  from,  292 

of  cervix,  251 

Caput  succedaneum,  155, 190 
Carcinoma  of  pelvic  bones.  2C2 
Central  placenta  prsevia,  302 

rupture  of  perineum,  283 

Cephalic  version,  382 
Cephalotribe,  400 
Cephalotripsy  v.  cranioclasm,  395 
Cervix,    Artificial    dilatation    of, 

203,  248 

,  Cancer  of,  251 

— ,    Dilatation   of,    in   placenta 

prsevia,  315 
— -,    Dilatation    of,     to    induce 

labour,  435 
,  Disease  of,  causing  rupture 

of  uterus,  272 

■ ,  Fibroid  of,  259 

,  Forceps,  dilatation  of,  355 

,    Imperfect    Dilatation     of, 

hindering  after-coming  head,  56 
■ ,    Injuries  to,    in    contracted 

pelvis,  153 
,  Irritation     of,     to     induce 

labour,  431 
■^— ,  lacerations  of,  Haemorrhage 

from,  342 

,  Rigidity  of,  246 

Chain  saw,  Use  of,  392 
Chamberlain  on  opiates  in  linger 

ing  labour,  118 
Champetier's  bag,  437 
— — in    accidental    hsemor 

rhage,  300 
— in  placenta  prsevia,  316 

323 
■ in  slow  first  stage,  249 

251 

• ,  Use  of,  204 

Champneys    on    kyphotic   pelvis 

224 
Change  in  presentation,  149 
Child,  Effects  of  contracted  pelvis 

on  head  of,  154 

,  Excessive  size  of,  103,  429 

,  Hrjuries    to,    in   breech  de- 
livery, 58 
Children,  Malformed,  103 
Chloral    in    slow     dilatation     of 

cervix,  248 
Choice  of  leg  in  turning,  389 


Chorda  prsevia,  84 
Chorion,  Retention  of,  329 
Cicatricial  tissue  in  cervix,  250 
Classification        of        contracted 
pelves,  134 

of  pelves  according  to  degree 

of  contraction,  193 
Clavicle,  Fracture  of,  59 
Cohen  on  placenta  prsevia,  318 
Cold  douche  to  abdomen,  334 
Collapse  after  haemorrhage,  349 
Combined  version,  384 
Common     forms     of     contracted 

pelvis,  134 
Complete  and  incomplete  rupture 
of  perineum,  284 

■ of  uterus,  271 

Compression    of    aorta    in    post- 
partum haemorrhage,  341 

■ of  uterus,  340 

with  forceps,  366 

Concealed,      accidental      haemor- 
rhage, 2  )6 
Configuration    of    body    in    con- 

ti  acted  pelvis,  165 
Congenitil  dislocation  of  femora, 

Pelvis  of,  243 
Conjugate,  Diagonal,  172 

External,  169 

,  true,  Direct  measurement  of, 

176 
Contracted    pelves,    Classification 

of,  134 
pelvis   and    pelvic    presenta- 
tions, 34 

causing  prolapse  of  cord, 

86 
causing  transverse  pre- 
sentations, 65 

,  Champetier's  bag  in,  437 

,  Dangers  of,  161 

,  Definition  of,  133 

,  Diagnosis  of,  164 

,  Long  first  stage  in,  248 

making  face  present,  15 

Mechanism     of      labour 

with,  180 

■ ,  Mixed  forms  of,  245 

,  Premature  labour  in,  429 

,  Rare  forms  of,  211 

,  Results  of,  148 

,  Symphysiotomy  for,  417 

,  Treatment     of     labour 

with,  193 
Contraction,  Hour-glass,  329 

,  Absence  of  uWrine,  129 

,  Imperfect  uterine,  326 

,  Partial,  of  uterus,  130 

,  Tonic,  of  uterus,  72,  125 

,  Uterine,  withoutretraction,336 

Cord,  Anomalies  of,  81 

,     Pressure    on,     in    breech 

labours,  36 
,  Prolapse  of,  84 


444 


Difficult  Labour. 


Cord,  Prolapse  of,  in  flat  pelvis, 
206 

,     Shortness      of,      inverting 

uterus,  347 

Coxalgio  pelvis,  241 

Cranioclasm,  398 

Cranioclasm  v.  cephalotripsy,  395 

Cranioclast,  395 

Craniopagus,  112 

Craniotomy  forceps,  395 

in  cancer  of  cervix,  252 

— — .  Indications  for  immediate, 
203 

in  flat  pelvis,  197 

in  small  round  pelvis,  210 

Crede's  mode  of  managing  third 
stage,  333 

Crotchet,  394 

Cullingworth,  Axis  traction  for- 
ceps of,  378 

Curves  of  forceps,  361 

Cystio  kidneys,  109 

Dangerous  zone,  Barnes's,  302 
Dauber's  forceps,  362 
Death,  Intra-uterine,  430 

,    Modes    of,    after    placenta 

prae-via,  312 
Decapitation,  404 

in   transverse  presentations, 

76 

Decidua,  Disease  of,  causing  acci- 
dental haemorrhage,  295 

,     ,      causing       placenta 

praavia,  306 

Deformity  of  head  in  contracted 
pelvis.  157 

,  with   occipito-posterior 

positions,  8 

Degeneration    of   uterus    causing 

rupture,  263 
Delivery,    Modes    of    natural,    in 
transverse  presentations,  65 

,  Methods  of  rapid,  439 

Penman  on  spontaneous  version,  66 
Diagnosis  between  tonic  contrac- 
tion    of     uterus     and     uterine 
inertia,  127 
— — ,  Importance  of  early,  1 
•— ,  Importance  of  early,  in  con- 
tracted pelvis,  161 

of  contracted  pelvis,  164 

of  twins,  94 

Diagonal  conjugate,  172 
Digital  pulling  in  breech  labour,  42 
Dilatation    of    cervix,    Artificial, 
203,  248 

in  placenta  prasvia,  315 

to  induce  labour,  435 

— —  of  soft  parts,  Slow,  246 
Dilating    bag   of    Champetier   de 

Kibes,  437 
Dinting  of  foetal  head,  159 
Diprosopus,  HI 


Dipygus,  111 

Dislocation,  so-called,  of  femora, 
Effect  on  pelvis  of,  243 

Displacement  of  arm,  77 

,  Dorsal,  of  arm,  48,  79 

Dolicho-cephalus,  19 

Dorsal  displacement  of  arm,  48,  79 

Double-headed  monsters,  112 

Double  monsters,  111 

Douche,  Vaginal,  to  induce  labour, 
432 

Douglas  on  spontaneous  evolu- 
tion, 68 

Drainage  in  rupture  of  uterus,  279 

Dropsy,  General,  of  foetus,  105 

Dublin  mode  of  managing  third 
stage,  333 

Duhrssen  on  iodoform  gauze 
plugging,  338 

Duncan,  Matthews,  on  hour-glass 
relaxation,  830 

, ,on  inversion  of  uteru  s,  345 

,  ,  on  premature  uterine 

retraction,  128 

,  ,   on    uterine  obliquity 

causing  face  presentation,  19 

Duncan's,  Matthews,  callipers,  167 

Dtthrssen's  method  of  rapid  de- 
livery, 439 

Dwarfs  pelvis,  212 

Early  diagnosis,  Importance  of,  1 

,    ,    in    contracted 

pelvis,  161 

Elastic  ligature  in  Caesarian  sec- 
tion, 417 
Electricity  in  post-partum  hsemor- 

rhage,  335 
Elongation,      Hypertrophic,      of 

cervix,  251 
Embolism,  Pulmonary,  from  per- 

chloride  of  iron,  337 
Embryotomy,  392 
Emotion       causing       accidental 

haemorrhage,  294 

suspending  uterine  action,  120 

Emphysema,  Foetal,  106 
Encepnalocele,  110 
Enchondromata  of  pelvis,  261 
Endometritis        after        placenta 

prsevia,  312 
Endometrium,      Smoothness      of, 

causing  placenta  praevia,  306 
Enucleation  of  fibroid,  259 
Epignathus,  110 
Ergot,  Action  of,  122 
causing  rupture  of  uterus,  272 

in    accidental    haemorrhage, 

298,301 

,  Indications  for,  123 

in  placenta  prsevia,  319 

in  postr-partum  haemorrhage, 

335 
in  premature  labour,  431 


Index. 


445 


Ergot  in  uterine  inertia,  117 
Erosion,  Haemorrhage  from,  292 
Evisceration,  403 

for  excessive  size  of  child,  105 

Evolution,  Spontaneous,  68 
Excessive  size  of  child,  103,  429 
Exhaustion  of  uterine  contractile 
power,  336 

,  Uterine,  116 

Exostoses  of  pelvis,  260 
Expression  of  cord,  84 
Expulsion,  Spontaneous,  70 
Extemporised   raised   pelvis   posi- 
tion, 278 
Extension  of  foetal  spine  in  occi- 
pito-posterior  positions,  5 

of  head  in  flat  pelvis,  182 

in     occipito-posterior 

positions,  5 
,   Result    of,  in    occipito-pos- 
terior positions,  6 
External  rectification  of  occipito- 
posterior  positions,  9 

version,  382 

Extraction  with  forceps,  374 

Face,    occipito-posterior    position, 
How  changed  into,  7 

position  in  flat  pelvis,  205 

presentation,  Causes  of,  15 

,  Moulding  of  head  in,  33 

,  Treatment  of,  21 

,  Turning  for,  380 

(with  flat  pelvis,  186 

Fallopian  tubes,  Removal  of,  418 
False  promontory,  172 
Fascia,  pelvia,  Injury  to,  282 
Femora,  So-called  congenital  dis- 
location of,  244 
Femur,  Injuries  to,  59 
Fever,    Puerperal,   after   placenta 
praevia,  313 

—— ,  ,  with  contracted  pelvis, 

162 
Fibroids,  Haemorrhage  from,  292 

,  Labour  with,  257 

of  cervix,  257 

Fibromata  of  pelvic  bones,  262 
Fillet  in  breech  labours,  44 
Fistulas,  urinary,Production  of,  153 
Flat  pelvis,  137 

,  Forceps  in,  356 

,    Mechanism    of    labour 

with,  180 

,    Treatment    of    labour 

with,  193 

,  Turning  for,  380 

Flattening  of  foetal  skull,  158 
Flexion,  Methods  of,  in  occipito- 
posterior  positions,  12 
— —    of    head,    in    small    round 

pelvis,  1S9 
■ ,  why  imperfect    in   occipito- 
posterior  positions,  4 


Foetal  anasarca,  105 

causes  of  face   presentation, 

21 

death.    Cause    of,    in   pelvio 

presentations,  36 

emphysema,  105 

head,  Effect  of  flat  pelvis  on, 

187 

,    of   small   round 

pelvis  on,  191 

heart,  Effect  of  pains  on,  123 

or  lying  down  pelvis,  242 

pelvis,  135 

Foetus,  Excessive  size  of,  103 

,  Intra-uterine  death  of,  430 

,  Malformation  of,  103 

— -,  Tumours  of,  110 
Foot,  Prolapse  of,  80 
Forceps,  353 

,  Axis  traction,  377 

,  Dauber's,  362 

for  the  breech,  46 

in   accidental   haemorrhage, 

in  descent  of  hand,  78 

in  flat  pelvis,  204 

in  occipito-posterior  posi- 
tions, 10 

in  placenta  praevia,  319 

in  prolapse  of  cord,  92 

in  small  round  pelvis,  210 

rotation  in  occipito-posterior 

positions,  13 

,  Tearing  vagina  with,  281 

to  after-coming  head,  63 

Fourchette,  Tears  of,  282 
Fracture  of  pelvic  bones,  164,  241 
Friction  opposing  delivery,  363 
Fronto- cotyloid  position  of  head. 

4 
Funis,  Anomalies  of,  81 

,  prolapse  of,  Turning  for,  381 

,  Replacing,  90 

Funnel-shaped  pelvis,  214 

Galabin  on  pendulum  movement, 
363 

on   pulling  with   forceps   in 

axis  of  brim,  377 

Galvanism,  Induction  of  labour 
by,  431 

Gauze,  iodoform,  in  labial  hema- 
toma. 291 

,  — ,  i*  rupture  of  uterus, 

279 

,  ,  Plugging  uterus  with, 

336 

plugging  for  lacerations    of 

cervix,  343 

General  dropsy  of  foetus,  105 
Generally  -  contracted     flat      non- 
rickety  pelvis,  211 
Genitals,    Wounds    of,    in    preg- 
nancy, 292 


446 


Difficult  Labour. 


Giffard  on  sedatives  in  lingering 

labour,  118 
Grooves  on  foetal  head,  159 
Growth,  Change  in  shape  of  pelvis 

during,  136 

Hoematoma,  Labial,  290 

of  sterno-mastoid,  60 

Haemorrhage,  accidental,  Turning 
for,  381 

after  delivery,  325 

before  delivery,  292 

— -,  Cerebral,  from  forceps 
delivery,  368 

• ,  Collapse  after,  349 

from  umbilicus,  83 

in  placenta  prsevia,  307,  311 

,  Intracranial,  160 

,  Meningeal,  61 

,  Post-partum,  after  acciden- 
tal, 301 

, ,  Production  of,  117 

, ,  with  fibroids,  258 

Hamilton  of  Falkirk  on  compres- 
sion of  uterus,  340 

Hand,  Descent  of,  with  head,  77 

,  in  uterus,  334 

Hardie's  measurement,  172 

Head,  after-coming,  Delivery  of, 
50 

,  detruncated,  Extraction  of, 

407 

fcetal,   Effects  of  contracted 

pelvis  on,  154 

, ,  Effect  of  flat  pelvis  on, 

187 

, ,  Effect  of  small  round 

pelvis  on,  192 

,  Large  size  of,  causing  face 

presentation,  17 

,  Most  favourable  position  of, 

in  flat  pelvis,  204 

,  Moulding  of,  29 

,  ,   in   occipito  -  posterior 

position,  8 

■ ,  Shape  of,  causing  face  pre- 
sentation, 19 

with  hand,  Presentation  or, 

77 

Heart,  fcetal,  Effects  of  pains  on, 

123 
Hegar's     dilators     in    accidental 

haemorrhage,  300 
in  placenta  prsevia,  315, 

324 
Hicks,  Braxton,  Cephalotribe   of, 

400 
,  ,  on  obstructed  labour, 

125 

■ , ,  on  placenta  prsevia,  313 

, ,  on  temporary  passive- 

ness.  117 
Hip   disease,  Deformity  of  pelvis 

from,  241 


History,  previous,  Value  of,  161 

Hook,  Blunt,  44 

, ,  to  axilla,  105 

,  Oldham's  vertebral,  398 

,  Kamsbotham's,  405 

Hot  water,  Injection  of,  334 

^Hour-glass  contraction  of  uterus, 
329 

Humerus,  Fracture  of,  59 

Hydramnios  and  breech  presenta- 
tions, 35 

causing  prolapse  of  cord,  86 

causing  transverse  presenta- 
tions, 64 

causing  weak  pains,  119 

,    Treatment   of   delay  from, 

125 

Hydrocephalus,  105 

Hydrothorax,  Fcetal,  109 

Hypertrophic  elongation  of  cervix, 
251 

Ice  in  post-partum  hsemorrhage, 

334 
Impaction,  Forceps  in,  358 

in  small  round  pelvis,  209 

Imperfect  uterine  contraction,  326 
Incomplete  rupture  of  uterus,  271 
Induction  of  labour  in  small  round 

pelvis,  208 

of  premature  labour,  429 

of   premature  labour  in   flat 

pelvis,  194 
Diertia,  Forceps  for,  357 
of  uterus  causing  postpartum 

haemorrhage,  332 
— — ,  Primary  uterine,  115 

,  Secondary  uterine,  116 

,  Uterine,  in  first  stage,  249 

Inflammation  of  pelvic  bones,  164 
Injection,  Saline,  into  veins,  350 

, ,  into  cellular  tissue,  352 

Injuries  to  childin breech  delivery, 

58 

to  genital  canal  indelivery,  281 

to  soft  parts  in  contracted 

pelvis,  153 
Insanity  after  placenta  prse via,  313 
Dospiration,  Premature,  in  breech 

labours,  36 
Instrument    for    symphysiotomy, 

426 
Instruments  needed  for  Caesarian 

section,  412 
Litercristal  measurement,  168 
Interlocking  of  twins,  98 
Internal  version,  388 
Interspinous    measurement,     (in- 
terior), 168 

(posterior),  170 

Interstitial      pregnancy      causing 

rupture  of  uterus,  263 
Intracranial  hsemorrhage ,  160 
lutra-uterine  death  of  foetus,  430 


INDEX. 


447 


Intravenous  saline  injection,  350 
Inversion  of  uterus,  344 
Inversion  of  uterus  by  fibroid,  253 

by  short  cord,  83 

Inverted  pelvis,  244 

Iodoform  gauze  for  laceration  of 

cervix,  343 

in  labial  hsematoma,  291 

in  rupture  of  uterus,  279 

,   Plugging'  uterus   with, 

336 
Irritation  of  cervix  to  induce  labour, 

432 
Iron,  Perchloride  of,  336 
, ,  for  lacerations  of  cervix, 

243 
Ischio-pagus,  112 

Jaw,  Injuries  to,  in  delivery,  61 
traction  on  after-coming  head, 

51 
Johnson's   method    of    measuring 

true  conjugate,  176 

Kaltenbach's   theory   of   placenta 

prsevia,  302 
Kidneys,  Cystic  disease  of,  109 
Kiwisch's      mode      of      inducing 

labour,  432 
Knots  in  the  cord,  81 
Krause's     method     of     inducing 

labour,  433 
Kypho-skolio-rachitic  pelvis,  225 
Kyphotic  pelvis,  220 

Labial  hsematoma,  290 

Labour,    Induction     of,     in    flat 

pelvis,  194 
,  in  small  round  pelvis, 

208 
,  natural,  Changes  in  uterus 

during,  264 

, -,  denned,  1 

,  Obstructed,  125 

■ , ,    causing     rupture     of 

uterus,  263 

,  Precipitate,  131 

,    premature,    Induction     of, 

429 

, ,  in  placenta  previa,  309 

,     -with      contracted      p*lvis, 

Mechanism  of,  180 

,  "Waleher's  position  in,  379 

with  twins,  94 

Lacerations    of    cervix,    Hsenior- 

rhage  from,  342 
La  Chapelle,  Madame,  Manoeuvre 

of,  374 
. , ,    on     cold    douche    to 

abdomen,  335 
, ,    on   delivery  of    after- 
coming  head,  58 
Lateral  asymmetry,  158 
placenta  prsevia,  302 


Leg,  Choice  of,  in  turning,  3Su 

■ ,  How  to  bring  down,  40 

,  When  to  bring  down,  38 

Levator  ani,  Rupture  of  fibres  of, 

282 
Lever  on  displacement  of  bladder, 

120 
Litzmann    on    most     favourable 
position  of  head  in  flat  pelvis, 
205 
■  on  premature  uterine  retrac- 
tion, 128 
Locked  twins,  98 

,  Decapitation  in,  404 

Loops  of  cord  round  child,  81 
Lower  uterine  segment,  265 
Lying-down,  or  foetal  pelvis,  242 

Malformed  children,  103 

Malpresentations,  149 

,  Conditions  which  cause,  20 

from  fibroids,  25S 

in  placenta  prsevia,  310 

Manual  rotation  in  face  presenta- 
tions, 24 

in  occipito-posterior  posi- 
tions, 13 

Marginal  placenta  prsevia,  302 

Mc  Ulintock  on  labial  hsematoma, 
290 

Measles,  Placenta  prsevia  after.  306 

Measurements  of  false  pelvis,  168 

-,  of  pelvis,  165 

Mechanism  of  jaw  traction,  52 

of    labour    with    contracted 

pelvis,  180 

Membranes,  Adhesion  of,  causing 
weak  pains,  119 

,  Premature  rupture  of,  247 

,  Retention  of,  329 

,  Rupture    of,    in    accidental 

haemorrhage,  299 

,  Rupture     of,     in    placenta 

prsevia,  315 

,  Rupture  of,  to  induce  labour, 

431 

,  Separation     of,     to     induce 

labour,  432 

Meningeal  hemorrhage,  61 

from  forceps  delivery,  368 

Meningocele,  110 

Menstruation  in  pregnancy,  292 

Milne  Murray  on  axis  traction  for- 
ceps, 378 

Mixed  forms  of  contracted  pelvis, 
245 

Mobility  of  uterus,  Abnormal,  in 
contracted  pelvis,  148 

Monsters,  Double,  111 

Mother,     disease    of,     Premature 

labour  for,  430 
Moulding  of  head,  29 

in  occipito-posterior  posi 

tions,  8 


448 


Difficul  t   Labour, 


Muller  on  accouchement  ford,  816 

on  placenta  prsevia,  313 

Muller's  modification  of  Caesarian 

section,  417 
Multipara,  Ruptured  uterus,  why 

frequent  in,  a72 
Murray,  Milne,  on  axis    traction 

forceps,  378 

Naegele,  Oblique  pelvis  of,  231 
,  Obliquity  of,  183 

on      pseudo   -    osteomalacic 

rickety  pelvis,  217 

Natural    delivery    in     transverse 

presentations,  65 
- —   labour,    Changes   in    uterus 

during,  264 

pains,  114 

,  what  it  is,  1 

Neglect,  Results  of,  in  transverse 

presentation,  71 
Nipping  of  soft  parts,  in  labour, 

with  flat  pelvis,  200 

Oblique  pelvis  of  Naegele,  231 

Obliquity  of  Naegele,  183 

of  uterus  causing  face  presen- 
tation, 17 

and  descent  of  hand,  77 

causing  pelvic  presenta- 
tions, 34 

causing  transverse  pre- 
sentations, 63 

,  Posterior  parietal,  184 

Obstetric  history,  Value  of,  165 

Obstructed  labour,  125 

causing    rupture     of 

uterus,  263 

Occipito-posterior  positions,  3 
,  Moulding  of  head 

in,  29 

— ,  Treatment  of,  8 

Oldham's  perforator,  393 

vertebral  hook,  398 

Opium  in  slow  dilatation  of  cervix, 

248 

in  uterine  inertia,  118 

Os  externum,  Smallness  of,  251 

internum,       Fixation      of 

shoulder  below,  391 

Osiander  on  rupture  of  vagina,  270 
Osteomalacia,  164 

,  Porro's  operation  for,  421 

Osteomalacic  pelvis,  228 
Outlet,  Measurement  of,  171 
Ovarian  tumour,  Labour  with,  254 
Ovariotomy  in  labour,  256 

,  Vaginal,  257 

Oxytocics,  124 

Packing  vagina  to  induce  labour, 

432 
Pains,  Anomalies  of,  114 
in  contracted  pelvis,  160 


Pains  in  placenta  prsevia  309 

,  Weakness  of,  115 

,  Weak,  with  breech  presenta- 
tion, 41 

,  what  are  natural  ?  114 

Pajot's  manoeuvre,  377 

Palpation,  External,  in  placenta 
prsevia,  314 

Parrot  on  anchondroplasia,  212 

Partial  contraction  of  uterus,  129 

placenta  preevia,  302 

Passiveness,  Temporary,  of 
uterus,  115, 127 

Pedicle  of  ovarian  tumour,  Twist- 
ing of,  255 

Pelves,  contracted,  Classification 
of,  134 

Pelvic  bones,  Tumours  of,  260 

fascia,  Injury  to,  282 

presentations,  Causes  of,  34 

,  Kinds  of,  34 

,  Prognosis  in,  35 

Pelvimetry,  165 

,  Importance  of,  in  flat  pelvis, 

196 

Pelvis,  Contracted,  causing  pro- 
lapse of  cord,  86 

, ,  causing  transverse  pre- 
sentations, 65 

,  ,   Champetier's   bag   in, 

437 

, ,  Dangers  of,  161 

, ,  defined,  133 

, ,  Diagnosis  of,  164 

, ,  Mechanism    of    labour 

with,  180 

, ,  Mixed  forms  of,  245 

, ,  Rare  forms  of,  211 

, ,  Results  of,  148 

, ,  Slow  first  stage  in,  248 

, ,  Symphysiotomy  for,  424 

, ,  Treatment    of    labour 

with,  193 

,  Contraction  of,  causing  face 

presentation,  15 

, ,  and  premature  labour, 

429 

,  Coxalgie,  241 

deformed     by     fracture    of 

bones,  241 

,  Dwarf's,  212 

,  false,  measurements  of,  168 

,  Flat,  137 

, ,    Treatment    of    laboui 

with,  193 

,  Foetal,  135 

, ,  or  lying-down,  242 

,  Funnel-shaped,  214 

,  Generally-contracted,  141 

, ,    fiat,    non-rickety, 

211 

,  Inverted,  244 

,  Kypho-skolio  rachitic,  225 

.  Kyphotic,  220 


Index. 


449 


Pelvis,  Oblique,  of  Naegele,  231 

,  Obtecta,  241 

of  congenital    dislocation    of 

femora,  244 

,  Osteomalacic,  228 

,  Production  of  shape  of,  135 

,  Pseudo-osteomalacic   rickety, 

216 

,  Rickety,  143 

,  Skolio-rachitic,  21? 

,  Small  round,  141 

, rickety,  213V 

, ,  Treatment  oflabour 

with,  208 
— -,  Split,  240 
,  Transversely    contracted,    of 

Robert,  234 
,    tumours      of,      Premature 

labour  for,  429 
Pendulous  belly,  63,  149,  202 
causing      rupture      of 

vagina,  270 
Pendulum  movement   of  forceps, 

363 
Perchloride  of  iron,  336 
for  lacerations  of  cervix, 

348 
Perforation,  393 

of  prsevia  placenta,  318 

Perineum,  Liability  to  rupture  of, 

in  occipito-posterior  positions,  9 

,  Rupture  of,  283 

Pent  jueal  toilette,  416 
Peritonitis  after  placenta  prsevia, 

313 

from  perchloride  of  iron,  337 

Phlebitis,  Uterine,  after  placenta 

prsevia,  307,  312 
Phlegmasia  dolens  after  placenta 

prsevia,  313 
Placenta,  Adhesion  of,  326 

born  before  child,  311,  317 

,  How  detached  when  prsevia, 

309 
,  Perforation  of  when  prsevia, 

318,  323 

,  retention  in  vagina,  326 

,  Separation  of  by  short  cord, 

82 

, ,  in  breech  delivery,  37 

, ,  when  prsevia,  318,  322 

prsevia,  301,  302 

causing   transverse  pre- 
sentations, 65 

,  Forceps  in,  360 

,  Turning  for,  380 

Placentse,  Suceenturiate,  328 
Plugging  for  laceration  of  cervix, 

343 

in  placenta  prsevia,  319 

uterus,  338 

vagina  in  accidental  haemor- 
rhage, 301 
Podalic  version,  383 

DD — 3G 


Polypu?,  Haemorrhage  from,  292 

Porro's  operation,  421 

for    osteomalacic   pelvis. 

231 

in     accidental     hcemor- 

rhage,  301 

in  rupture  of  uterus,  279 

Portal  on  turning  in  placenta 
prsevia,  316 

Posterior  parietal  position  in  flat 
pelvis,  205 

Post  -  mortem  Caesarian  section, 
411 

Post-partum  haemorrhage,  325 

after  accidental,  301 

in  contracted-  pelvis, 

162 

,  Production  of  117 

with  fibroids,  258 

Postural  treatment  of  descent  of 
hand,  78 

of  prolapse  of  cord,  88 

Prague  method  of  delivering 
after-coming  head,  54 

Precipitate  labour,  131 

Pregnancy,  Haemorrhage  during, 
292 

,  Menstruation  in,  292 

Premature  delivery,  Pelvic  pre- 
sentations with,  34  -__ 

inspirations  in~  breech  de- 
liveries, 36 

labour,  First  stage  long   in, 

246 

,  Induction  of,  429 

in  flat  pelvis,  194 

in  placenta  prsevia,  309 

rupture  of  membranes,  247 

uterine  retraction,  128 

Presentation  of  cord,  84 

Presentations,  Abnormal,  in  pla- 
centa prsevia,  310 

,  Change  of,  149 

in  twin  labour,  94 

Pressure  from  above  on  after 
coming  head,  51 

marks  on  foetal  head,  155 

Primary  uterine  inertia,  115,  249 

Production  of  kyphotic  pelvis,  220 

of  post-partum  hsemorrhage, 

117 

Prolapse  of  cord,  84 

in  flat  pelvis,  206 

of  foot,  80 

of  funis,  Forceps  with,  360 

,  Turning  for,  3S1 

— —  of  hand,  77 

,  Relation  between  rupture  of 

periueum  and,  285 

Prolongation  of  labour  in  con- 
tracted pelvis,  162 

Promontory,  False,  172 

Promontory,  Marks  on  head  by, 
155 


45° 


DlFFICUL  t    La  bo  ur. 


Pseudo  -  osteomalacic  rickety 

pelvis,  216 

Puerperal  fever  after  placenta 
preevia,  313 

with   contracted  pelvis, 

162 

Pulmonary  embolism,  after  pla- 
centa preevia,  313 

-— from  perchloride  of  iron, 

337 

Puncture  of  ovarian  tumour,  254 

Pyaemia  after  placenta  preevia,  307, 
312 

from   sloughing   of   skin   of 

head,  157 

with  contracted  pelvis,  163 

Pygopagus,  112 

Raised  pelvis  position,  278 
Ramsbotham,    J.,    on   accidental 

haemorrhage,  293 
Eamsbotham's  sharp  hook,  405 
Rapid  delivery,  Methods  of,  439 
Rectification,   External,   of    occi- 

pito-posterior  positions,  9 

of  transverse  presentations,  74 

,  Spontaneous,  65 

Rectum,  Cancer  of,  253 

,    Fulness    of,    causing   weak 

pains,  120 
Reflex  stimulation  of  uterus,  335 
Relative  weakness  of  pains,  120  - 
Replacement  of  cord,  89 
Retention  of  membrane,  329 
Retraction,  Premature  uterine,  128 
Retroversion    of     gravid     uterus 

from  contracted  pelvis,  148 
Rickety  pelvis,  143 

,      Pseudo-osteomalacic, 

216 

,  Small  round,  213 

,    Treatment    of    labour 

with,  193 

Rigby  on  accouchement  force",  316 

on  haemorrhage  during  preg- 
nancy, 293 

Rigidity  of  cervix,  246 

Ring  of  Bandl,  201,  267 

Robert,  Transversely  contracted 
pelvis  of,  234 

Roper's  craniotomy  forceps,  396 

Rostrate  pelvis,  230 

Rotation,  Early,  in  small  round 
pelvis,  190 

forceps   in   occipito-posterior 

positions,  13 

-  for  dorsal  displacement  of 
arm,  79 

in  occipito-posterior  posi- 
tions, 3 

Rotation,  Manual,  in  face  pre- 
sentations, 24 

,  ,     in     occipito-posterior 

positions,  13 


Rotation  of  foetus  from  shortening 

of  cord,  83 
Rupture  of  membranes  in  placenta 
preevia,  315 

,  Premature,  247 

to  induce  labour,  431 

of    ovarian    tumour    during 

labour,  254 

of  perineum,  283 

in     occipito-posterior 

delivery,  9 

of  uterus,  263 

from  fibroids,  258 

from  spiny  pelvis,  260 

in    transverse    presenta- 
tions, 72 

,  with  hydrocephalus,  106 

,  with  small  round  pelvis, 

191 

of  vagina,  270 

in  transverse   presenta- 
tions, 72 

Sacral  teratoma,  110 

Saline  intravenous  injection,  350 

Sapreemia,  with  contracted  pelvis, 

163 
Sarcoma  of  pelvic  bones,  262 
Scanzoni  on  uterine  inertia,  115, 

117 
Scar  tissue  making  cervix   rigid, 

277 
Schatz's  method  of  rectifying  face 

presentations,  22 
Scissors  for  evisceration,  412 
Secondary  uterine  inertia,  116 
Section,  Abdominal,  for  rupture  oi 

uterus,  277 

,  Caesarian,  409 

Segment,  Lower  uterine,  265 
Separation     of      membranes      to 

induce  labour,  432 
Septicaemia        with       contracted 

pelvis,  163 
Shortening  of  cord,  82 
Short  forceps,  362 
Shoulder,   Fixation   of,    below  os 

internum,  391 
Shoulders,  Excessive  size  of,  103 

,  Rupture  of  perineum  by,  283 

Sigault's  operation,  424 
Simpson,    Sir   J.,  on  dorsal   dis- 
placement of  arm,  79 
, ,  on  placenta  preevia,  311, 

317 
Size  of  child,  Excessive,  429 
Skin  of  foetal  head,  Marks  on,  155 
Skolio-rachitic  pelvis,  217 
Sloughing  of  vagina,  280 
Small  round  pelvis,  141 
,  Mechanism  of  laboui 

with,  188 
,  Treatment  of  labour 

with,  208 


Index. 


45i 


Small  round  rickety  pelvis,  213 
Smellie,   method    of   delivery    of 

after-coming  head,  51 

on  forceps  rotation,  13 

' on    transverse     position    of 

1    head,  181 

Spencer  on  diagnosis  of  placenta 

prsevia,  314 
on  intracranial  haemorrhage, 

160 
Spina  bifida,  110 

Spine,  Injuries  to,  in  delivery,  60 
Spiny  pelvis,  260 
Split  pelvis,  240 
Spondylolisthesis,  236 
Spondyl-olizema,  241 
Spondylotomy,  408 
Spontaneous  evolution,  68 

expulsion,  70 

rectification,  66 

version,  66 

Sterilisation,  418 

Sterno-mastoid,  Hsematoma  ox,  60 
Stimulation  of  uterus,  334 
Strictures  of  uterus,  130 
Buccenturiate  placentae,  328 
Suture  of  lacerated  cervix,  343 

of  ruptured  perineum,  287 

■ of  ruptured  uterus,  277 

Sutures,  Over-riding  of,  157 
Symphysiotomy  ,198,  225,  424] 
Syncope,     Fatal,    with     placenta 

preevia,  312 
Syphilis,  430 

Tait,  Lawson,  on   Porro's  opera- 
tion, 422 
Tapping  in  hydrocephalus,  107 

of  ovarian  tumour,  254,  255 

Tarnier,  Axis  traction  forceps  of, 

378 
Tears  of  vagina,  280 
Tenotomy  knife  for  symphysiotomy, 

426 
Tents,    Induction    of   labour    by, 
435 

in  placenta  prsevia,  315 

Teratoma,  Sacral,  110 
Thorny  pelvis,  260 
Toco-dynamometers,  122 
Toilette  of  peritoneum,  416 
Tonic  contraction  of  uterus,  72,  125 

with  fibroids,  258 

Traction  on  jaw  of  after-coming 

head,  51 
Transfusion,  350 
Transverse  presentations,  62 

,  Decapitation  in,  404 

,  Treatment  of,  74 

,  Turning  for,  380 

Transverselv  contracted  pelvis  of 

Kobert,  234 
True  conjugate,  Direct   measure- 
ment of,  176 


Trunk,  foetal,  Morbid  enlargement 

of,  110 
Tumours  causing  transverse  pre- 
sentation, 65 

of  foetus,  110 

of  pelvic  bones,  260 

of   pelvis,  Premature   labour 

for,  429 

,  ovarian,  Labour  with,  254 

Turning,  380 

,  Advantage  of,  in  flat  pelvis, 

207 
for    dorsal    displacement    ol 

arm,  79 

in  descent  of  hand,  78 

in  face  presentations,  24 

in  flat  pelvis,  205 

in  placenta  prsevia,  316 

in  prolapse  of  cord,  91 

in  transverse  presentations,  74 

Twin  labours,  94 

,  Accidental  haemorrhage, 

in,  301 
Twins  and  breech  presentations,  35 

,  Locked,  98 

, ,  Decapitation  in,  404 

Twisting   of    pedicle   of    ovarian 

tumour,  255 

Umbilical  cord,  Anomalies  of,  81 
Umbilicus,  Hsemorrhage  from,  89 
Ureter,  Tearing  of,  281 
Urethra,  Dnperforate,  109 
Uterine  action,  Abnormal,  114 

,  How  to  judge  of,  151 

atony,  332 

exhaustion,  116 

inertia  in  twin  labours,  96 

,  Primary,  115,  249 

,    prolonging   first  stage, 

249 

,  Secondary,  116 

retraction,  Premature,  128 

suture  in  Caesarian   section, 

414 
Utero-vesical  fistula,  153 
Uterus,  Abnormal  mobility  of,  in 

contracted  pelvis,  148 

,  Absence  of  retraction  of,  129 

,  Compression  of,  340 

,  Effect  of  placenta  praevia  on, 

307 

,  Hour-glass  contraction  of,  329 

,  How  to  stimulate,  334 

,  Imperfect  contraction  of,  326 

,  Inversion  of,  344 

, ,  by  fibroid,  259 

, ,  by  short  cord,  83 

,  Nipping  of,  in  labour  with 

flat  pelvis,  200 
,   Obliquity  of,   and    descent 

of  hand,  77 
, ,  causing  face  presenta- 
tion, 17 


452 


Difficult  Labour. 


Uterus,     Obliquity     of,     causing 

pelvic  presentations,  34 
, ,  causing  transverse  pre- 
sentations, 63 

,  Partial  contraction  of,  130 

,  Plugging  of,  with  gauze,  338 

,  Retroversion  of  gravid,  from 

contracted  pelvis,  148 

,  Rupture  of,  263 

, ,  from  fibroids,  268 

, ,  from  spiny  pelvis,  260 

, ,  in  flat  pelvis,  201 

, ,  in  transverse  presenta- 
tions, 72 

, ,     with     hydrocephalus, 

106 

, ,  with  small  round  pelvis, 

191 

,  Strictures  of,  130 

,  Temporary    passivenesa     of, 

115,  127 

,  Tonic  Contraction  of,  72,  125 

, ,  with  fibroids,  258 

,  Weakness  of,  causing  trans- 
verse presentations,  63 

Vagina,  Cancer  of,  253 

,    Injuries    to,    in    contracted 

pelvis,  153 

,  Nipping  of,  in  flat  pelvis,  200 

,  Packing  of,  to  induce  labour, 

432 

,  Plugging   the,  in   accidental 

haemorrhage,  301 

,  Rupture  of,  270 

, ,  in  transverse  presenta- 
tions, 72 

, ,  with  flat  pelvis,  202 

,  Tears  of,  280 

Vaginal  Caesarian  section,  439 

douche  to  induce  labour,  432 

ovariotomy,  257 

Vaginal  plugging  in  placenta 
preevia,  319 


Variability  of  position  of  head  in 

small  round  pelvis,  190 
Varicose  veins  and  labial  hsema- 

toma,  290 
Vectis   in   occipito-posterior   posi- 
tions, 12 
Vein,  Entrance  of  air  into,  312 
Veins,  Varicose,  and  labial  hsoma- 

toma,  290 
Version,  External,  382 
for    dorsal    displacement    of 

arm,  79 

in  accidental  haemorrhage,  300 

in  descent  of  hand,  78 

in  prolapse  of  cord,  91 

in  placenta  preevia,  316 

in  transverse  presentations,  74 

,  Spontaneous,  66 

Vertebra,  Malformation  of,  causing 

spondylolisthesis,  236 
Vertebral  hook,  Oldham's,  398 
Vertex  presentations,  Moulding  of 

head  in,  2!) 
Vesico-vaginal  fistula,  153 
Vulva,  Cancer  of,  253 
,  Injuries  of,  282 

Walcher's  position,  379 

"Water  bag  of  Champetier  de  Ribes, 

437 
bags  in  placenta  prtevia,  315, 

323 
Weakness    of     pains     in     breech 

labours,  41 
Weak  Pains,  115 

in  contracted  pelvis,  151 

Whartonian  jelly,  Atrophy  of,  81 

Wire  ecraseur,  392 

Wounds  of  genitals  in  pregnancy, 

292 

Zone,  dangerous,  of  Barnes,  302 
Zweifel's    mode    of     compressing 
uterus,  340 


Printed  by  Cassell  &  Co.,  Limitkd,  La  Belle  Sauvaoe,  London,  E.C. 
20.5.03 


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A  000  421  795 


WQ310 
H551d 
1908 


Herman,  George  Ernest. 
Difficult  labor. . . 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

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